MultiLife and Guaranteed Standard Issue Step 1 of 2 50% Adviser Information Are you new to working with Secura Consultants?*YesNoAdviser Name*Company Name*Phone*FaxEmail* Address*Street*City*State*Zip Code Client Information Company Name*IndustryDate Offer Proposal is Needed:*MM/DD/YYYYEffective Date of Coverage Requested*MM/DD/YYYYCompany Website AddressType of Company Entity?*C-CorpS-CorpPartnershipLLCSole ProprietorshipTotal Number of Employees?*Number to be considered for the offer?*Occupations of the group to be considered?*Premium to be paid by:*EmployerEmployee Current Coverage Information Individual DI In Force On Any Participants*YesNoDon't KnowDetailsGroup LTD In Force On Any Participants*YesNoDetailsWill any of these coverages be replaced?*YesNoDetailsWhich coverage?Income to be covered by plan: Salary Commissions Overtime Bonus Other Details on "other" income to be covered by plan:*For proper plan design, we must have data based on a specific census format. Please download the form below, complete it and upload it back to us via our secure system below.Download the census form. CLICK HERE! Upload the completed census form below! Plan Design Requested Benefit Amount*Elimination Period*30 days60 days90 days180 days365 daysBenefit Period*24 months60 monthsTo Age 65To Age 67To Age 70Optional Riders Residual Catastrophic COLA Enhanced Owner Occupation Retirement Full MNDA Other Other: Optional Riders*Other 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. Group LTD Plan documents, current census in Secura Consultants format are REQUIRED. If you haven't, please download the form below, complete it and upload it back to us via our secure system below.Download the census form. CLICK HERE! Upload documents to us via our secure system.Attach relevant files such as financial statements, existing policies, medical records, etc.FileFileFileFileFileCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.