The Smith Companies, Ltd.

Disability Proposal Request Form

In order to properly assess your clients eligibility for Disability Insurance we would ask that you completely fill out this questionnaire. Each question is vital and thus we would ask that you answer each and every question. If you have any questions or concerns please contact Jonathan Smith.

Mulitlife Form

Most Human Resource Departments will have a Company Census that they can forward to you for use with Multi Life Requests. We would suggest that you make sure their Census contains the same fields provided in this Template. If they do not have one to provide then please feel free to use this Template as a guide. For fastest response it is best if we receive the Census in Excel Format, by email. Please include in your email any specific plan designs that you are interested in proposing to your clients. If you have any questions or concerns please contact us.

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Disability Proposal Request Form
The Smith Companies, Ltd.
Fax: # 617.367.6120

Date:

Check One: Deliver Pick-Up Call Fax Mail Email

Broker:

Address:

City, State, Zip Code:

Telephone Number: Fax Number:

Email Address:

Applicant: DOB/AGE:

Resident State: Check which apply: Male Female Smoker NonSmoker Other Tobaco

Occupation: % Ownership :

Years of Ownership : Years at Occupation:

Related Education & Certifications: # of Employees:

Office in Home: Yes No

Exact Duties

Annual Income Plan/Policy

Existing Coverage Yes No

If yes, Benefit Amount:
Base: SIS:

GLTD% of Replaced Income: Monthly Cap:

Elimination Period: Benefit Period:

Employee/Employer Paid: Contributing to SS: Yes No

Group or Individual:

Disability Proposal Request Form

Mulitlife Form

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