Fields with * are required
CLIENT INFORMATION
Name:
*  Date of Birth:
Gender:			Select Male Female
*  Home State:			Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*  Smoker:			Select Yes No if quit, last use was on:
Height:
Weight:
Medical Problems/Medications & Dosage:
Annual Income:			This Year: Last Year:
Occupation:
DUTIES		% Admin:	% Travel:
		% Sales:	% Manual
		% Management:	% Other:
CLIENT EMPLOYMENT STATUS
Business Owner	Select Yes No	Type of Entity:	Select Sole Prop Partnership LLC LLP C-Corp S-Corp
Years in Business:
Number of Employees:		Office in residence:	Select Yes No
Time Away from Residence			%
Government Employee:	Select Yes No	Agency:	Select Federal State Country City
Number of years:
Other DI/LTD inforce:			Select Yes No
Individual Monthly Benefit $:
Group Percentage:		Group Maximum:
Other/Comments:
DISABILITY INSURANCE INFORMATION
Product Options
Most important:   Cost    |   Superior Benefit
Monthly benefit:   Maximum    |   How Much?
Premium:   Level    |   Step-Rate    |   Employer Paid    |   Employee Paid
DI Products
Elimination 30 60 90 ALL	Benefit 12 18 24 months ALL	Riders None Replacement Expense All
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Comments
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