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BIP Disability Quote Request
DI Audit Questionnaire
Individual Long Term Disability/ Business Overhead
Producer Information
Producer Name
*
First
Last
Producer Company Name
*
Phone
*
Email
*
Producer Broker Dealer or National Account Affiliation
Send proposal to
Client Information
Name
*
First
Last
Date of Birth
*
Month
Day
Year
State Residence
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Gender
*
Male
Female
Tobacco Use?
*
Yes
No
Occupation
*
Title
*
Duties
*
Years in Current Position
*
Work From Home?
*
Yes
No
If yes, % of time working at home
Annual Income
*
(Net Income if Business Owner or Salary if Employee)
Bonus
Unearned
Self-Employed or Business Owner
*
Yes
No
If less than 1 full tax year in business:
Former Occupation/Duties
Former Salary
Individual Case Design
Requested Benefit Amount
Max
Elimination Period
30 Days
60 Days
90 Days
180 Days
365 Days
720 Days
Benefit Period
6 Months
1 Year
2 Years
5 Years
10 years
To Age 65
To Age 67
To Age 70
Lifetime
Optional Riders
Own Occupation
Residual/Partial
Cost of Living Adjustment
Catastrophic Benefit
Future Purchase Option
Automatic Increase Option
Recovery Benefit
Return of Premium
Retirement Completion Product
Yes
No
Retirement Plan Income Deferral
Premium
Level
Step Rate
Premium Payor
Employee
Employer
Business Overhead Expense Case Design
Monthly Expenses
Requested Benefit Amount
Max
Elimination Period
30 Days
60 Days
90 Days
Benefit Period
12 Months
18 Months
24 Months
Optional Riders
Residential/Partial
Professional Replacement
Future Purchase Option
Return of Premium
In force BOE Coverage Amount
Coverage InForce
(Check all appropriate boxes)
Is there Group LTD coverage in force?
Yes
No
Replacement Percentage
Benefit Cap or Maximum
Elimination Period
Benefit Period
GLTD Coverage Employee %
GLTD Coverage Employer %
Taxable Benefits
Yes
No
Income Covered
Salary
Overtime
Bonus
Commissions
(Check all that apply)
Is there Individual disability coverage in force?
Yes
No
Individual DI Carrier
Benefit Amount
Elimination Period
Benefit Period
Individual Coverage Employee %
Individual Coverage Employer %
Taxable Benefits
Yes
No
Is there competition on the case? If Yes, provide details.
Medical Complications?
Past 5 years. Medications taking? Height & Weight?
Please select your DI Brokerage Rep.
*
Brad
CJ
Ryan
Charles
