Individual Disability Plans Step 1 of 3 33% Adviser Information Are you new to working with Secura Consultants?*YesNoAdviser Name*Company Name*Phone*FaxAddress*Street *City*State*Zip CodeEmail* When are you meeting with your client? Client Information Is your client a medical professional?YesNoName of teaching institution, hospital or clinicName*Date of Birth*MM/DD/YYYYGender*MaleFemaleState of Residence*Tobacco Used*YesNoQuitLast Date Used*MM/DD/YYYY Medical Information Height*Feet & InchesWeight*LbsMedications and DosagesHas there been a weight change of more than 10 pounds in the last year*YesNoDetails*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): High blood pressure, chest pain, heart murmur or disorder of the heart or circulatory system? Details* Diabetes, cancer, tumor, disorder of the thyroid, pancreas or lymph nodes or disorder of the glands, bone, blood or skin? Details* Complication of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys, or urinary system? Details* Hernia, Hepatitis or disorder of the liver, gall bladder, appendix, stomach, intestines or rectum? Details* Arthritis, rheumatism, gout or disorder of the joints, limbs or muscles? Details* Disorder or condition of the back, neck or spine including “wellness” chiropractic visits? Details* Tuberculosis, allergies, asthma, sinusitis, emphysema, or disorder of the lungs or respiratory system? Details* Epilepsy, stroke, dizziness, headaches, paralysis or disorder of the brain or spinal cord? Details* Disorder of the eyes, ears, nose or throat? Details* Anxiety, depression, nervousness, stress, mental or nervous disorders, or other emotional disorders or counseling for personal or work-related issues? Details* Chronic Fatigue Syndrome, Epstein Barr virus or Lyme disease? Details* Treatment for drug or alcohol abuse or use of any controlled substances? Details* Has your client been rated, declined or offered modified coverage from any life or health insurance carrier? Details* Visited a physician, clinic or medical practitioner for treatment of any disease or disorder or been advised to begin any treatment program? Details* Employment Information Occupation*Job Duties*Length of Employment*Work out of the home?*YesNoDoes the client own their own business?*YesNoPercent of ownership?How long have you owned the business?Number of employees?Is this a start up or an existing business?What form of business?C CorpS CorpSole ProprietorshipPartnershipLLCWould you like a proposal for Business Overhead Expense coverage?YesNoWhat is the client’s share of the monthly expenses?Would you like a proposal for Disability Buy-Sell Coverage?YesNoWhat is the value of the business?Buy Sell Elimination Period12 months18 months24 monthsLump Sum?YesNoMonthly Funding?YesNo Taxability of Premium/Benefit Information Who will be paying the premium?*EmployerEmployeeWhat will the tax treatment be of the proposed coverage?*TaxableNon-TaxableDo you want to see a retirement plan proposal?*YesNo Income Information Enter Income after business expenses, but before taxes. Annual Salary: Salary: Most Recent/CurrentSalary: Last complete tax yearCommissions and/or Bonus:Commissions and/or Bonus: Most Recent/CurrentCommissions and/or Bonus: Last complete tax yearHas the bonus and/or commission been consistent for the last 3 years?YesNoIf no, explain:* Existing Disability Insurance Is there existing disability insurance?YesNoIndividual DI Amount:Individual DITaxable BenefitTax Free BenefitGroup LTD Amount:Group LTDTaxable BenefitTax Free BenefitAdditional Details Plan Design - Individual DI Elimination Period*30 days60 days90 days180 days265 days720 daysBenefit Period*6 months12 months2 years5 years10 yearsTo age 65To age 67To age 70LifetimeOwn Occupation Period*2 years5 yearsTo age 65To age 67To age 70LifetimeOptional 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 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. 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.*YesNoUpload DocumentsAttach financial statements, existing policies, medical records, etc.FileFileFileFileFileCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.