Kleinschmidt Insurance—Disability Income Insurance Quote Request

QUOTE FORMS

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CLAIMS

Please complete this form as completely and accurately as possible and submit it to us when you are finished. If you wish, you may also print out the form and fax it to us (734•662•5379) or call our office with this information.

Note that we cannot provide coverage until a policy or binder has been issued by the insurance company. As part of our quoting process, we may need to verify some information such as credit history, prior insurance history, and financial stability information.

Contact Information
Name:
Street address:
City:
State:
Zip code:
County:
Phone (home):
Phone (work):
Fax:
Email address:
Quote Information
Date of birth (mm/dd/yy):
Gender: Male Female Tobacco User: No Yes
Height (ex. 5'8") Weight (ex. 150 lbs)
Occupation:
Exact duties:
Business owner? Yes No Number full-time employees:
Office in residence: Yes No Number of years owned:
Current annual income (include all compensation: bonuses, dividends, etc.—documentation will be required):
Is there disability coverage currently in force? Yes No
If 'Yes' how much?
Current carrier:
Most important: Cost Benefit Desired annual benefit:
Desired benefit period: 5 years 10 years Until age 65	Desired waiting/elimination period: 30 days 60 days 90 days
Employer paid? Yes No
Please describe any and all health conditions you have (or have had in the past and/or any medications you are currently taking):
Additional Considerations/Requests
Please add any additional comments you feel appropriate for this quotation.