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:
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Job Title:
Duties:
Employee 4:
Name:
Age or DOB:
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Duties:
Employee 5:
Name:
Age or DOB:
Gender:
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Duties:
Employee 6:
Name:
Age or DOB:
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Duties:
Employee 7:
Name:
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Duties:
Employee 8:
Name:
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Employee 9:
Name:
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Employee 10:
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Employee 11:
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Employee 12:
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Employee 13:
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Employee 14:
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Employee 15:
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Employee 16:
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Employee 17:
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Employee 18:
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Employee 19:
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Employee 20:
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Employee 21:
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Employee 22:
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Employee 23:
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Employee 24:
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Employee 25:
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Employee 26:
Name:
Age or DOB:
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Employee 27:
Name:
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Employee 28:
Name:
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Employee 29:
Name:
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Employee 30:
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Employee 31:
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Employee 32:
Name:
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Employee 33:
Name:
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Employee 34:
Name:
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Employee 35:
Name:
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Employee 36:
Name:
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Employee 37:
Name:
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Employee 38:
Name:
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Employee 39:
Name:
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Employee 40:
Name:
Age or DOB:
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End of LTD Census Table
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