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OneSource Brokerage, Inc.                

 

 
 

DISABILITY QUOTE

Agent Information
Agent Name:   

 
Phone:
 
Fax:
 
Email:
 
Application Sign State:
 

Before presenting or selling Disability Insurance, please make sure you hold your Health License in the appropriate states.
 

Client Information
Client Name:   

   
Birth Date: //
   
Gender: Male  Female
   
State of Residence:
   
Tobacco Use:
   
Height:   
Weight:   
Medical History /
Medication:
   
Occupation:
   
Job Duties:
   
Salary:
                         		 Commissions/ Bonus:
                        (3 year average)
   
Government Employee:    
Yes  No     Years of Service:
   
Business Owner:    
Yes  No
   
   
% Ownership		    

   
   
Years Owning Business:		    
   
   

   
   
Years Working in Industry:		    
   
   

   
   
Number of Employees:		    
   
   

   
   
% of work done in home:		    
   
   

   
 

In Force Coverage
Has existing coverage:    
   
   
   
Yes  No 
   
   
Existing group coverage:		    
   
   
   
   
Yes  No 
   
Premium payer:
   
% replacement:		    
  Monthly Cap:
   
Existing individual coverage:		    
   
   
   
Yes  No 
   
Is coverage being replaced:		    
   
   
   
Yes  No 
   
Premium payer:		    
   
Benefit Amount:		    
 

Policy Information
Elimination Period:   

   
Benefit Period:   

   
Benefit Amount:   
     Max Benefit
   
Riders:   
Residual               3% COLA
 Catastrophic       6% COLA
 Own Occupation Guaranteed Insurability
 Non-cancelable  Social Security Offset
   
Carriers: Illinois Mutual MetLife Principal
 Standard Mutual of Omaha Assurity
Additional Information:   

   
 
Delivery Information
   
How would you
like to receive:		    
   
   
Email  Fax
   
   
This quote is needed by:		    
   
   
//
   
 


If we have all information needed to accurately
quote your client, please expect your proposals
within 24 hours. If otherwise, we will contact you.