Request Disability Quote - Multi-Life/Guarantee Issue

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:

Policy Information
* Company Name:
* Address:
* Nature of Business:
* Years Business:
* Entity: C-Corp
S-Corp
Partnership
LLC
LLP
Sole Prop
* Number of Employees: Full Time
Part Time
* Number in Eligible Group:
* Nature of
Eligible Group:
All
Other (describe-execs, managers and key employees)
* Is this company
already a client?
No
Yes (describe other plans you have put in place)
* Describe employee turnover in last 2 years:
* With respect to eligible group?
* Describe business stability in last 3 years (i.e.: growth of company, profitability, layoff history, etc.):
* Describe any known medical histories (attach page if needed)

Competition
* Is there competition on this policy? No    Yes
If yes, name of carrier:
Type of product:
(individual, group, association, etc.)
Nature of offer:
(any guarantees, maximum coverage, etc)

Existing Coverage
Group STD: Carrier:
Waiting Period
Benefit Period
Formula:
%  Base Only to a / month maximum
%  Base + Bonus to a / month maximum
Premium paid by:
% Employer
% Employee

Group LTD: Carrier:
Waiting Period
Benefit Period
Formula: %  Base Only to a / month maximum
%  Base + Bonus to a / month maximum
Premium paid by: % Employer
% Employee

Individual Employer
sponsored coverage:
Carrier:
Waiting Period
Benefit Period
Benefit Amount: / month maximum
Premium paid by:
% Employer
% Employee
Payroll Deduction

Underwriting Request
* Name of Product applied for:
Premium paid by:
% Employer
% Employee
* Coverage will: Supplement
Replace
STD
LTD
Individual
* Contract to Quote:
* Effective Date:
* Start Date:
* Enrollment Period: Weeks Months
* Who will do the field underwriting on the policy? Self
Self and others (describe)
* If employees are not local, how will applications be taken?
* Describe your marketing plan:
* Billing: New List Bill
Existing List Bill
Direct Bill
Other
Additional Policy Info:
Send Illustration Via: E-Mail     Mail     Fax

Disability insurance policy form 1200 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.