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Doing Business with DIL
Needs Analysis
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LTC | DI | Annuity Quotes
Underwriting Forms
XRAE Underwriting Tool
Underwriting Tools
Contracting & Licensing
Policy Service
Core Carriers
Sales & Marketing
Annuity
Disability
Long Term Care
Life Insurance
About
About Us
Meet the Team
Contact Us
Your Life Department
DI Quote Request
Disability Proposal Request
Δ
AGENT INFO
Agent First Name
Agent Last Name
Email Address
License #
PROPOSED INSURED INFO
Proposed Insured First Name
Proposed Insured Last Name
State of Residence
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date of Birth
Gender
Male
Female
Height
Weight
Nicotine Use
-Select-
No use of any type ever
No Cigarette use for 5+ years
No Cigarette use for 3+ years
No Cigarette use for 12+ months
Cigarette use in last 12 months
Cigar use only (indicate frequency below)
Chewing tobacco use only
Nicotine gum/patch only
Other (explain below)
Marijuana/Cannabis Use
-Select-
No use ever
No use in last 5 years
No use in last 12 months
Use 5-7 times per week
Use 1-3 time per week
Use occasionally - please define below
Insured Info Details and Comments
OCCUPATION INFO
Job Title
Occupation
Years with Employer
Years Self Employed
% of Time Working at Home
Employment Status
Employee
Self-employed
Industry
Earned Income
Earned Income YTD
Earned Income - Self-employed
Earned Income - Self-employed YTD
Number of Employees
SDI
Yes
No
Group DI Coverage
Yes
No
Government Employee
Yes
No
STRS / PERS
Yes
No
MEDICAL UW INFORMATION
Medical Conditions
Any heart problem ever
Any kind of cancer ever
Diabetes or Pre-diabetes
High blood pressure or cholesterol
Back, neck or spine problems
Joint problem
Arthrirtis
Depression or Anxiety
Any other Mental/Nervous condition
Stroke or TIA
Unknown Medical History
None of the Above
Medical History Details
Prescription Drugs
Yes
No
Prescription Drug Details
Previous Disability
Yes
No
Disability History
PRODUCT SELECTION
Product Type
Personal Disability Income
Business Overhead Expense
Lump Sum Key Person Disability
Lump Sum Buy-Sell Disability
Other - please describe in comments
Monthly Benefit Amount
-Select-
Maximum Allowed
1000
1500
2000
2500
3000
4000
5000
6000
7000
8000
9000
10000
11000
12000
13000
14000
15000
Other - Please describe in comments
Alternate Benefit Amount
-Select-
None
Maximum Allowed
1000
1500
2000
2500
3000
4000
5000
6000
7000
8000
9000
10000
11000
12000
13000
14000
15000
Other - Please describe in comments
Elimination Period
60 Days
90 Days
180 Days
365 Days
Other - please describe in comments
Benefit Period
2 years
5 years
10 years
To age 65
To Age 67
Lump Sum - key person and buy sell only
Other - please describe in comments
Riders
Own Occupation
Non-Cancellable
Social Income Rider
Residual or Partial Disability
Cost of Living Increase
Future Purchase Option
Other - describe in comments
Product Info Comments
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