Disability Worksheet

When will you need this illustration by? / /   Time: :

Agent Information:
Name: Phone: Email:

Client Information:
Name:  
Male: Female:
 
DOB:      
  Height:     feet   inches   Weight: lbs.
Married - Spouse Applying

Name of Spouse:  
Male: Female:
 
DOB:    
  Height:     feet   inches   Weight: lbs.

Married - Spouse Not Applying

Reason for not applying:

Single
Smoking: Has any person applying used tobacco/nicotine within the past 5 years?
Yes No
Driving: Have you driven an automobile at least 5 times during the past month?
Yes No

Benefit Selection:
Maximum Daily Facility Benefit: $
    [Min. $50/day; $10 increments; Max. $300/day]
Benefit Period:
  2 Years (730x)
  3 Years (1095x)
  3 Years (1095x)
  4-years (1460x)
  5-years (1825x)
  Lifetime (unlimited)

Maximum Lifetime Benefit:   $
    [Multiply Daily Facility Benefit amount by Benefit Period chosen.]

Maximum Home and Community-Based Care Benefit:
  50% [Maximum Daily Facility Benefit may not be less than $100.]
  75% [Maximum Daily Facility Benefit may not be less than $70.]
  100% [Maximum Daily Facility Benefit may not be less than $60.]
Elimiation Period:
  0 Days [Not available for ages 80+.]
  30 Days  
  60 Days  
  90 Days  
  180 Days [Not available with 2-year benefit period.]
  365 Days [Not available with 2-year benefit period.]
Inflation Benefit:
  None
  5% Simple
  5% Compound
  Deferred Purchase Option
Premium Payment Mode: Premium Payment Options:
 
(more than 1 item may be selected)
  BOM Monthly   Continuous Pay  
  Quarterly   10-Year Pay [may not be available]
  Semi-annual   20-Year Pay [may not be available]
  Annual   Single Pay [may not be available]

  Please list all medication(s):
 
Comments: