Kouzmanoff Financial

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Home/
Carriers/
Group LTD Plans/
Employee Benefits/
MARKETING RESOURCE ARTICLES/
DI Web Series/
Applications & Forms/
The Standard CA Electronic Application/
About Us/
Contact Us/
Submit a Quote Request/

Submit a Quote Request

Home/
Carriers/
Group LTD Plans/
Employee Benefits/
MARKETING RESOURCE ARTICLES/
DI Web Series/
Applications & Forms/
The Standard CA Electronic Application/
About Us/
Contact Us/
Submit a Quote Request/

Broker Information

Broker Name *

First Name

Last Name

CA License Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

Phone *

(###)

###

####

Client Information

Client Name *

First Name

Last Name

Sex *

Date of Birth (MM/DD/YYYY) *

State of Residence *

Tobacco or Nicotine use in the past 12 months? *

Occupation Information

Occupation *

Describe daily occupational duties: *

Employee of a government or public entity? (Ex: public school teacher) *

If OTHER, please explain:

How many years of government service?

What percentage of occupational duties is performed from the residence/home? *

How many hours PER WEEK does your client work in their occupation? *

Income Information

Income (after business expenses) from last tax filing: *

$

Income year to date:

$

Self-employed OR has >25% business ownership? *

If YES, how many years and how many employees?

Client's business operates as:

In-Force Coverage

Monthly Benefit of any INDIVIDUAL in-force coverage:

$

Percentage and Max. Monthly Benefit of any GROUP in-force coverage:

(ex: 60% up to $10,000)

Monthly Benefit of any BUSINESS OVERHEAD in-force coverage:

$

Premiums to be paid by: *

Individual Plan Information to be Quoted

Waiting Period (Days)

Benefit Period

Requested Monthly Benefit Amount

If left blank, maximum benefit amounts will be quoted

$

Optional Riders

All Riders

Residual/Partial

Future Purchase

COLA

ADL (CAT)

Business Overhead Plan Information to be Quoted

Waiting Period (Days)

Benefit Period (Months)

Requested Monthly Benefit Amount

If left blank, maximum benefit amounts will be quoted

$

Optional Riders

All Riders

Residual/Partial

Future Purchase

COLA

ADL (CAT)

Medical Information

Is your client taking any prescribed medications? *

If YES, what medication and for what condition(s)?

Any other special health or other underwriting considerations?

Thank you for your request!

We will contact you directly if any additional information is needed to create your quote.

Home/
Carriers/
Group LTD Plans/
Employee Benefits/
MARKETING RESOURCE ARTICLES/
DI Web Series/
Applications & Forms/
The Standard CA Electronic Application/
About Us/
Contact Us/
Submit a Quote Request/

Kouzmanoff Financial

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