INDIVIDUAL QUOTE

Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

Note: If you do not hear back from us within 24 hours, please call 800-955-0040. Ask for Don or Lisa. Thank you!

*We respect your right to personal privacy. To that end, we collect and use the information you provide to us for quoting purposes only. The information we collect is never shared with other organizations and/or for commercial purposes. If you have any questions or concerns regarding this statement, please contact Don by email at: dthomas@dwassociates.com.

Quote Request Form

Broker Information

First Name:
Last Name:
CA Lic:
Phone:
Fax:
Email:
Address:
City: State: Zip:

Client Disability Insurance Information
Individual Disability Income Policy - All occupations including most blue collar

Business Overhead Expense

Business Equity Protector (DI Buy-Out) Call us for case review and illustration

Client General Information

Name:
Date of Birth (mm/dd/yyyy):

Business Owner? % Owned: Years Owned:

Sole Proprietor S-Corp C-Corp Partnership Other

Occupation:

Describe Job Duties: Please provide detail for accurate classification: Owner?, % in office, Manual Labor? Other relevant information?

Gender: male female

Employer Sponsored Plan? yes no

Tobacco User? yes no

Quote assumes good health with appropriate height and weight, and all policies are contingent on complete financial and medical underwriting.

Special underwriting medical conditions or medications:

Waiting Period: 60 90 180 365 730

Benefit Period: 2 5 65 66/67

Earned Income:
(after business expesnses, before taxes)

Inforce Coverage: $

Group LTD Ind DI Replacment? yes no

Benefit Amount Requested: or Maximum Available

Supplemental Social Insurance: or Maximum available

Fixed 5% COLA, if available: yes no

Indexed CPI COLA, if available: yes no

Own Occupation Rider if available : yes no
(Limited to most white collar risks)

Noncancelable Rider if available: yes no
(Limited to most white colar risks)

Extended Residual Rider: yes no
(Partial earnings loss)

Future Purchase Option: yes no

Need quote by:

Return by: mail fax email

For more info contact:

Don L. Thomas, CFP
Brokerage Director
dthomas@dwassociates.com
Toll Free (800) 955-0040 Option 2

Lisa Young
Disability Specialist
Underwriting Manager
lyoung@dwassociates.com
Toll Free (800) 955-0040 Option 1

Karen Simmons
Underwriting Assistant
New Business
ksimmons@dwassociates.com
Toll Free (800) 955-0040 Option 3

YOUR LOCAL DISABILITY PARTNER

INDIVIDUAL QUOTE

Quote Request Form