Program Manager, Michael L. Crifasi, CFP

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Disability Income Request

Please fill in the information requested so that we can email you a proposal specific to your state. The required fields are indicated in bold.

Insured's Information

Name:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone 1:
Phone 2:
FAX:
E-mail Address:
Height:
Weight:
Occupation
Medical History
Have You Ever Used Tobacco?
Date of Last Use:
List all health conditions, dates, and medications with dosage.
Existing Coverage/Income Gross Annual Income Level
Base last year ($)
Base 2 years ago ($)
Other Income ($) Source of Other Income
Unearned income ($)
How many years in your current profession?
Do you have existing Disability coverage? (List carrier name)
Answer the following questions if you have existing coverage.
Current coverage is:
Type of coverage
Is coverage being replaced?
Current: Waiting period Benefit Period Benefit Amount
Do you have a partial, residual, rehabilitative, or return to work benefit?
Desired Coverage
Monthly coverage amount($) Waiting Period (Days)
Benefit Period (Years)
Premium Mode
The following are optional rider, click here for definitions.
Social Insurance Rider (SIR)
Extended Partial Disability
Future Insurability Option
Cola