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General Information

Agent Name	Agent Email
Agent Phone	Date Illustration Needed
Deliver Illustration via Email Fax	Send Application Yes No
Do you need to be contracted? Yes No	Send Product kit? Yes No

Client Information

Name	DOB
Gender Male Female
Tobacco Usage None Cigarettes Pipe Cigar Chew
State of Residence	Job Title
Job Duties
Annual Income $
Other DI coverage (employer offered, etc)

Business Owner

Number of Employees

How long have they owned the business?

Please pick company & product for me

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Our recommendations

To age 65
Residual disability
90 day elimination period
COLA (Cost of living allowance)

Choose the Benefit Details

Insurance Company Assurity Illinois Mutual Met Life Principal Standard
Monthly Benefit $
Elimination Period 30 Days 60 Days 90 Days 120 Days 180 Days
Other
Benefit Period 2 Years 5 Years Until Age 65
Other Options Own Occupation 2 Years 5 Years Until Age 65 Residual Disability Partial Disability COLA (Cost of living allowance)
Future increase option Maximum Amount
Social Security Offset Automatic Increase Catastrophic disability benefit (Principal only)

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