Individual Disability Plans Step 1 of 3 33% Adviser Information Adviser InformationAre you new to working with Secura Consultants?*YesNoAre you new to working with Secura Consultants?Adviser Name*Adviser NameCompany Name*Company NamePhone*PhoneFaxFaxAddress*Street Address*City*State*Zip CodeEmail* EmailWhen are you meeting with your client?When are you meeting with your client? Client Information Client InformationIs your client a medical professional?YesNoIs your client a medical professional?Name of teaching institution, hospital or clinicName of teaching institution, hospital or clinicName*NameDate of Birth*MM/DD/YYYYDate of BirthGender*MaleFemaleGenderState of Residence*State of ResidenceTobacco Used*YesNoQuitTobacco UsedLast Date Used*MM/DD/YYYYLast Date Used Medical Information Medical InformationHeight*Feet & InchesHeightWeight*LbsWeightMedications and DosagesMedications and DosagesHas there been a weight change of more than 10 pounds in the last year*YesNoHas there been a weight change of more than 10 pounds in the last yearDetails*DetailsIn the last five years, has your client been treated for or received medical treatment for any of the following (Please Check all boxes that apply): High blood pressure, chest pain, heart murmur or disorder of the heart or circulatory system? In the last five years, has your client been treated for or received medical treatment for any of the following (Please Check all boxes that apply):Details*Details Diabetes, cancer, tumor, disorder of the thyroid, pancreas or lymph nodes or disorder of the glands, bone, blood or skin? Details*Details Complication of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys, or urinary system? Details*Details Hernia, Hepatitis or disorder of the liver, gall bladder, appendix, stomach, intestines or rectum? Details*Details Arthritis, rheumatism, gout or disorder of the joints, limbs or muscles? Details*Details Disorder or condition of the back, neck or spine including “wellness” chiropractic visits? Details*Details Tuberculosis, allergies, asthma, sinusitis, emphysema, or disorder of the lungs or respiratory system? Details*Details Epilepsy, stroke, dizziness, headaches, paralysis or disorder of the brain or spinal cord? Details*Details Disorder of the eyes, ears, nose or throat? Details*Details Anxiety, depression, nervousness, stress, mental or nervous disorders, or other emotional disorders or counseling for personal or work-related issues? Details*Details Chronic Fatigue Syndrome, Epstein Barr virus or Lyme disease? Details*Details Treatment for drug or alcohol abuse or use of any controlled substances? Details*Details Has your client been rated, declined or offered modified coverage from any life or health insurance carrier? Details*Details Visited a physician, clinic or medical practitioner for treatment of any disease or disorder or been advised to begin any treatment program? Details*Details Employment Information Employment InformationOccupation*OccupationJob Duties*Job DutiesLength of Employment*Length of EmploymentWork out of the home?*YesNoWork out of the home?Does the client own their own business?*YesNoDoes the client own their own business?Percent of ownership?Percent of ownership?How long have you owned the business?How long have you owned the business?Number of employees?Number of employees?Is this a start up or an existing business?Is this a start up or an existing business?What form of business?C CorpS CorpSole ProprietorshipPartnershipLLCWhat form of business?Would you like a proposal for Business Overhead Expense coverage?YesNoWould you like a proposal for Business Overhead Expense coverage?What is the client’s share of the monthly expenses?What is the client’s share of the monthly expenses?Would you like a proposal for Disability Buy-Sell Coverage?YesNoWould you like a proposal for Disability Buy-Sell Coverage?What is the value of the business?What is the value of the business?Buy Sell Elimination Period12 months18 months24 monthsBuy Sell Elimination PeriodLump Sum?YesNoLump Sum?Monthly Funding?YesNoMonthly Funding? Taxability of Premium/Benefit Information Taxability of Premium/Benefit InformationWho will be paying the premium?*EmployerEmployeeWho will be paying the premium?What will the tax treatment be of the proposed coverage?*TaxableNon-TaxableWhat will the tax treatment be of the proposed coverage?Do you want to see a retirement plan proposal?*YesNoDo you want to see a retirement plan proposal? Income Information Enter Income after business expenses, but before taxes. Income InformationAnnual Salary: Annual Salary:Salary: Most Recent/CurrentSalary: Most Recent/CurrentSalary: Last complete tax yearSalary: Last complete tax yearCommissions and/or Bonus:Commissions and/or Bonus:Commissions and/or Bonus: Most Recent/CurrentCommissions and/or Bonus: Most Recent/CurrentCommissions and/or Bonus: Last complete tax yearCommissions and/or Bonus: Last complete tax yearHas the bonus and/or commission been consistent for the last 3 years?YesNoHas the bonus and/or commission been consistent for the last 3 years?If no, explain:*If no, explain: Existing Disability Insurance Existing Disability InsuranceIs there existing disability insurance?YesNoIs there existing disability insurance?Individual DI Amount:Individual DI Amount:Individual DITaxable BenefitTax Free BenefitIndividual DIGroup LTD Amount:Group LTD Amount:Group LTDTaxable BenefitTax Free BenefitGroup LTDAdditional DetailsAdditional Details Plan Design - Individual DI Plan Design - Individual DIElimination Period*30 days60 days90 days180 days265 days720 daysElimination PeriodBenefit Period*6 months12 months2 years5 years10 yearsTo age 65To age 67To age 70LifetimeBenefit PeriodOwn Occupation Period*2 years5 yearsTo age 65To age 67To age 70LifetimeOwn Occupation PeriodOptional Provisions Own Specialty Your Occupation Transitional Own Occupation Residual/Partial Residual 24 months Cola (minimum) Cola (maximum) Catastrophic/ADL Rider Future Increase Option Automatic Increase Option Social Insurance Offset Rider Return of Premium Retirement Protection Benefits Optional ProvisionsSpecial Instructions?Special Instructions?Additional Information?Please provide information which may assist in generating an accurate illustration including information on special travel, avocations or hobbies, special work circumstances or history, etc. Additional Information?Would you like our Marketing Team to suggest the one carrier we feel provides the best value for your client? If you select no, multiple quotes will be provided.*YesNoWould you like our Marketing Team to suggest the one carrier we feel provides the best value for your client? If you select no, multiple quotes will be provided.Upload DocumentsAttach financial statements, existing policies, medical records, etc.Upload DocumentsFileFileFileFileFileFileFileFileFileFileCaptchaCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.