Key-Man Disability Income

Key-Man Disability Income Insurance can be extremely important. It helps the business concern continue the salary of a disabled executive without having to pay two salaries to get one job done.

It provides income when disability due to sickness or accident destroys the executive’s ability to earn his regular income.

Please complete the following questionnaire to permit us to provide you with a Key-Man Disability Income Proposal.

Key-Man Disability Income Quote 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

    Client Information

     

    Client

     

    Age

     

    DOB

     

    Gender

     

    State of Residence 

     

    State of Employment 

     

    Is the client a smoker? 

     

    Occupation

     

    Exact Duties:

     

    Does the client currently have any In-Force Disability Income Coverage? (Individual or group) 

     

    If yes, please give details (amount and coverage:

     

    Reported income from previous year: 

     

    Reported income from two years ago 

     

    Benefit Amount Requested: 

     

    Elimination Period: 

     

    Benefit Period: 

    Broker Supplies

     

    Need supplies? 

     

    Supplies requested:

    Remarks:

    How do you want the results sent to you? 
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