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:
* 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