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
FOR BROKER USE ONLY. NOT FOR PUBLIC USE.