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Preliminary Inquiry for Other Group Benefits- Not an application for insurance
Short Term Disability, AD&D, Life Insurance, Dependent AD&D, Dependent Life Insurance

Applicant Information

  Applicants Name   
  State of Residence   

Short Term Disability

P Plan Type Non-contributory     Contributory
P Injury Period   or Injury Elimination Period 
P Sickness Period  or  Sickness Elimination Period 
P Period of  or  Weeks Duration
    Class Description of Quote # Percent and Maximum or Flat Amount
P Number 1
P Number 2
  Number 3
P Optional Benefits Partial    Residual

  Voluntary Disability

    Plan 1 Plan 2 Plan 3 Plan 4
P Benefit Percent   
P Benefit Duration   
P Elimination Period   

Voluntary Term Life for Under 50 Lives

P Under 50 Lives   New Take Over       Dependent Life Yes  No
P Under 50 Lives   Dependent Rates: 2-tier  4-tier Dependent Waiver or
NO Dependent Waiver
P Under 50 Lives

  Guaranteed Issue Amount

Minimum Amount

Maximum Amount


Voluntary Term Life for 50+ Groups

P Over 50 Lives  New Take Over      
P Optional Benefits  Voluntary Life Voluntary AD&D Voluntary Dependent Life Voluntary Dependent AD&D
P Seat Belt Rider  Yes No       Dependent Plans:
P Tobacco Rates  Yes No       2-tier  4-tier
P Over 50 Lives

  Guaranteed Issue Amount
Check all that apply or enter value
$50,000 for under 100
$100,000 for over 100
Other (Please specify)

  Minimum Amount
  Check all that apply or enter value
$10,000 w/ AD&D
$20,00 w/o AD&D
Other (Please specify)

  Maximum Amount
  Check all that apply or enter value
Other (Please specify)



Agent Information

P Agent Name   
P Agency Name
P Address
P City
P State
P Phone
P Email
P Fax number
  Other Comments

Please be specific with above information and include phone numbers. 
It will expedite processing

Robert D. Fink and Associates  After filling out the necessary information on this form you will receive a quote via phone or email and then have the option of applying for the actual overage. There is no commitment for filling out the information on this form and receiving a quote.