Overhead Expense Disability Insurance

Fields marked with * are required.

Your Information
* Your Name:
Your Company:
* Your Address:
* Your City:
* Your State:
* Your Zip:
* Your Phone Number:
Your Fax Number:
* Your E-mail Address:

Insured Information
* Proposed Insured:
* Age or Date of Birth:
* State:
* Gender: Male    Female
* Tobacco User: None for 1 year or more
Cigarettes, Pipe or Chew
Cigar Only / How Often?
* Occupation (Specialty/Duties):
* % Time In Office:
* % Time Traveling for Business:
* Does client intend to reside or travel outside US? Yes    No
* US Citizen? Yes    No
Current Overhead Monthly Coverage: $
* Monthly Benefit Desired: $
* Benefit Period:
* Elimination Period:
* Available Riders: Residual
Future Increase Option
Is this part of a Batch Bill (3 or more lives)? Yes     No
Format: Premiums Only
Full Illustration
Full Illustration plus Additional Sales Material
Additional Policy Info:
Send Illustration Via: E-Mail     Mail     Fax

Policy form 4200 underwritten and issued by Berkshire Life Insurance Company of America, Pittsfield, MA, a wholly owned stock subsidiary of The Guardian Life Insurance Company of America, New York, NY. Product provisions and features may vary from state to state.

Opes One Advisors