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
50%
60%
50%
60%
50%
60%
50%
60%
P Benefit Duration
9 weeks
11 weeks
12 weeks
13 weeks
22 weeks
24 weeks
25 weeks
26 weeks
2 yrs to 70
5 yrs to 70
10 yrs to 70
RBD
9 weeks
11 weeks
12 weeks
13 weeks
22 weeks
24 weeks
25 weeks
26 weeks
2 yrs to 70
5 yrs to 70
10 yrs to 70
RBD
9 weeks
11 weeks
12 weeks
13 weeks
22 weeks
24 weeks
25 weeks
26 weeks
2 yrs to 70
5 yrs to 70
10 yrs to 70
RBD
9 weeks
11 weeks
12 weeks
13 weeks
22 weeks
24 weeks
25 weeks
26 weeks
2 yrs to 70
5 yrs to 70
10 yrs to 70
RBD
P Elimination Period
7 days
15 days
30 days
60 days
90 days
180 days
360 days
7 days
15 days
30 days
60 days
90 days
180 days
360 days
7 days
15 days
30 days
60 days
90 days
180 days
360 days
7 days
15 days
30 days
60 days
90 days
180 days
360 days
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
P Under 50 Lives
Guaranteed Issue Amount
$25,000
$50,000
$75,000
$100,000
Minimum Amount
$25,000
$50,000
$10,000
Maximum Amount
$125,000
$200,000
$50,000
$75,000
$100,000
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:
1
2
3
4
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(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 $250,000(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.
