Level Four Insurance - Disability Quote Step 1 of 3 - Agent Information 0% Agent InformationName*PhoneFaxEmail* Client InformationName*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleState of Residence*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificMarital Status*SingleMarriedDomestic PartnerWidowedDivorcedTobacco Use*YesNoMedical InformationHeightWeightMedications and DosagesIn the last five years, has your client been treated for a condition or received medical advice?List details aboveEmployment InformationOccupationJob DutiesLength of EmploymentWorks from home?NoYesWork at home detailsOwns their own business?NoYesHow many years have they owned their business?How many employees?Income Information Income after business expenses but before taxesAnnual SalaryBonusCommissionHas bonus/commission been consistent for the past three years?YesNoPlease explain inconsistent commissionenter details hereOther Coverage InformationDoes the client have any other disability benefits (including Std or Ltd)?If yes, please list details including taxability of the benefit, benefit maximums, elmination period, etc. Illustration InformationElimination PeriodNone30 Days60 Days90 Days180 Days365 Days730 DaysBenefit PeriodNone6 Months12 Months2 Years5 Years10 YearsTo Age 65Age 67Own Occupation PeriodNone2 Years5 YearsAge 65Age 67Age 70LifetimeWould you like a proposal for Business Overhead Expense (BOE) coverage?NoYesBOE DetailsPlease enter any details such as proposed insured's share of the monthly expenses.Would you like a proposal for Buy Sell coverage?NoYesBuy/Sell Coverage DetailsPlease list Buy/Sell coverage details including business value, trigger point, lump sum and monthly funding.Optional Provisions Own Occupation Modified Own Occupation Cola(Minimum) after 12 months of paid disability Cola(Maximum) after 12 months of paid disability Residual/Partial Future Increase Option Group Replacement/Supplement Rider Return of Premium Catastrophic/ADL Rider Social Insurance Offset Rider (not all riders are available on all products)Special InstructionsWould you like us to suggest the one carrier we feel provides the best value for your client?YesNo Δ
