Special Risk Disability Insurance Step 1 of 3 33% Adviser Information Are you new to working with Secura Consultants?*YesNoAdviser Name*Company Name*Phone*Fax*Address* Street Address City State / Province / Region ZIP / Postal Code Email* Client Information Name*Birthday* Date Format: MM slash DD slash YYYY Gender*MaleFemaleState of Residence*Tobacco Used*YesNoQuitLast Date Used* 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?*YesNoDetails*Does the client own their own business?*YesNoIf yes, details including the percentage of ownership, how long the prospect has owned the business, number of employees, etc? This is important information for obtaining the best occupation class available for your client.Would you like a proposal for Business Overhead Expense coverage?YesNoIf yes, what is the client’s share of the monthly expenses?dollarsWhat form of business?C CorpS CorpProprietorshipPartnershipLLCWould you like a proposal for Disability Buy-Sell Coverage?YesNoIf yes, provide 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-Taxable Income Information Enter Income after business expenses, but before taxes. Annual Salary: Most Recent/CurrentLast complete tax yearBonus:Most Recent/CurrentLast complete tax yearCommissions:Most Recent/CurrentLast complete tax yearHas the bonus or commission been consistent for the last 3 years?YesNoIf no, explain:* Other Coverage Information Does the prospect have any other disability benefits (including group STD or LTD)?*YesNoIf yes, Details including taxability of the benefits, benefit maximums, elimination period, etc.* Premium Budget Have you discussed a premium budget with your prospective client?YesNoWhat is it? Plan Design Elimination Period*30 Days60 Days90 Days180 Days365 Days730 DaysBenefit Period*6 months12 months2 years5 yearsOwn Occupation Period*2 years5 yearsOptional Provisions Residual COLA Own Occupation 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.*YesNoFileFileFileFileFileCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.