Retirement Protection Plus Program

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
* Past Year Income:
If Self-Employed, net Schedule C income AFTER business expenses: $
If Salaried, salary plus bonus: $
If Partner or S Corp principal, income from K-1: $
Current Personal Individual Monthly Coverage: $
Employer Paid Group: $
Personally Paid Group: $
* Retirement Plan Type:
* Retirement Plan Contribution:
Employee/Insured's Annual Retirement Plan Contribution: $
Employer's Annual Retirement Plan Contribution: $
* Monthly Benefit Desired:
Maximum Available
Request specific amount: $
* Benefit Period:
* Elimination Period:
Available Riders:
COLA 3% 6%
Future Increase Option Maximum
Specify $
Additional Case Info:
* Is this part of a multi-life Qualified Sick Pay Plan? Yes     No
* Send Illustration Via: E-Mail Mail Fax

Disability insurance Policy Form 1400 and 1500 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.