Group Long Term Disability Income (LTD)

Group Long Term Disability (LTD) is an employer-sponsored benefit designed to assist an employee replace income lost as a result of a disability.

The goal of a well designed LTD plan is to replace that portion of an employee’s lost income that approximates the employee’s pre-disability take-home pay.

While we do see some plans designed to replace as little as 50% of gross income, this is probably not realistic since most employee’s living expenses exceed this figure. Most commonly, plans are designed to replace 60% to 66% of gross income, including any income received from NY State DBL, Workers Compensation, or Social Security Disability Benefits.

Benefit Duration Benefits are usually payable to age 65 or normal retirement age
Elimination Period Benefits are usually payable after 30, 60, 90, or 180 days of disability
Maximum Covered Salary Frequently, highly compensated executives will discover that only a portion of their income is covered under the LTD Plan. Supplemental Executive Plans must then be implemented to augment the Executives group LTD benefit.

Long Term Disability Quote Request Form

Fields indicated with an asterisk * are required.
Broker Submitting Quote Request
* First Name
* Last Name
  Company
* Phone
  Extension
  Fax
* Email
  Address
   
  City
* State
  ZIP
Group Information
  Group Name
  Nature of Business: 
  Is this a "virgin" group with no prior LTD coverage? 
  County
  City
  State
  ZIP
  Requested Effective Date: 
  Do the employees contribute toward cost 
  Number of Employees: 
IMPORTANT: In addition to the information above, we must have:

  • Employee Census
  • Loss Experience

You may use the form below or attach your own form.

  Attach file: 
 
Skip table to submit with attached form
LTD Census Data
Employee 1:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 2:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 3:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 4:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 5:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 6:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 7:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 8:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 9:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 10:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 11:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 12:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 13:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 14:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 15:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 16:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 17:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 18:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 19:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 20:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 21:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 22:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 23:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 24:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 25:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 26:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 27:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 28:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Job Title:
Duties:
Employee 29:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 30:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 31:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 32:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 33:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 34:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 35:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 36:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 37:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 38:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 39:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
Employee 40:
Name:
Age or DOB:
Gender:
Annual Salary:
Job Title:
Duties:
End of LTD Census Table
 
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