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#1535 (no title)
USH&C Contract Request

DIS Proposal Request Form

Click here to download the paper copy of this form for submission by fax or email.

To submit this form online, please fill out the form below:

DIS Proposal Request Form

Quotes within 24 hours guaranteed!

Broker Information
Today's Date:
MM
DD
YYYY
Phone:
Fax:
Broker Name:*
Affiliation:
Address:
Street Address City State ZIP Code
Email or Fax To:
Client Information
Client Name:
DOB:
MM
DD
YYYY
Sex:
- Male
- Female
Tobacco User:
- Yes
- No
State
Net Annual Income:
Occupation:
Work From Home:
- Yes
- No
If Yes, Work From Home % of Time:
Company:
Check Any That Apply:
Multi-select capability. Hold 'CTRL' while selecting your choices to select more than one choice.
# of Employees:
Years In Business:
Government Employee?
- Yes
- No
Years of Government Employment:
Check Any That Apply:
Multi-select capability. Hold 'CTRL' while selecting your choices to select more than one choice.
Group LTD In Force?
- Yes
- No
Monthly Amount:
- 60%
- 67%
Employer Paid:
- Yes
- No
Individual Coverage In Force:
- Yes
- No
Monthly Amount:
To Remain in Force:
- Yes
- No
Occupation Duties:
Medical Issues or Other Comments:
Individual Disability Policy
Who will pay the premium?
- Employee
- Employer
Monthly Benefits:
Elimination Period:
- 60
- 90
- 180
- 365
Benefit Period:
- 2 Years
- 5 Years
- to age 65
- 66/67
Benefit Riders:
Multi-select capability. Hold 'CTRL' while selecting your choices to select more than one choice.
If Benefit Rider is SSIB:
If Benefit Rider is CAT:
Overhead Expense Policy
Monthly Benefit
Elimination Period:
- 30
- 60
- 90
Benefit Period:
- 12 months
- 18 months
- 24 months
Benefit Riders:
Multi-select capability. Hold 'CTRL' while selecting your choices to select more than one choice.

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812 Purple Martin Blvd. E., Griggsville, IL 62340. (217) 833-2741