MultiLife and Guaranteed Standard Issue Step 1 of 2 50% 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*PhoneFaxFaxEmail* EmailAddress*StreetAddress*City*State*Zip Code Client Information Client InformationCompany Name*Company NameIndustryIndustryDate Offer Proposal is Needed:*MM/DD/YYYYDate Offer Proposal is Needed:Effective Date of Coverage Requested*MM/DD/YYYYEffective Date of Coverage RequestedCompany Website AddressCompany Website AddressType of Company Entity?*C-CorpS-CorpPartnershipLLCSole ProprietorshipType of Company Entity?Total Number of Employees?*Total Number of Employees?Number to be considered for the offer?*Number to be considered for the offer?Occupations of the group to be considered?*Occupations of the group to be considered?Premium to be paid by:*EmployerEmployeePremium to be paid by: Current Coverage Information Current Coverage InformationIndividual DI In Force On Any Participants*YesNoDon't KnowIndividual DI In Force On Any ParticipantsDetailsDetailsGroup LTD In Force On Any Participants*YesNoGroup LTD In Force On Any ParticipantsDetailsDetailsWill any of these coverages be replaced?*YesNoWill any of these coverages be replaced?DetailsDetailsWhich coverage?Which coverage?Income to be covered by plan: Salary Commissions Overtime Bonus Other Income to be covered by plan:Details on "other" income to be covered by plan:*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! HTML BlockUpload the completed census form below!Upload the completed census form below! Plan Design Requested Plan Design RequestedBenefit Amount*Benefit AmountElimination Period*30 days60 days90 days180 days365 daysElimination PeriodBenefit Period*24 months60 monthsTo Age 65To Age 67To Age 70Benefit PeriodOptional Riders Residual Catastrophic COLA Enhanced Owner Occupation Retirement Full MNDA Other Optional RidersOther: Optional Riders*Other: Optional RidersOther 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. Other Information?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! HTML BlockUpload documents to us via our secure system.Attach relevant files such as financial statements, existing policies, medical records, etc.Upload documents to us via our secure system.FileFileFileFileFileFileFileFileFileFileCaptchaCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.