Brass Ring Financial Solutions – Disability Center
Disability Income Insurance: Simplified Issue; Return of Premium; Association discounts; Guarantee Issue; Short-Term DI; White, gray & blue collar plans;
Benefits to age 65, 70 and Lifetime
.
INDIVIDUAL DISABILITY PROPOSAL REQUEST

Broker Name_________________________________

Affiliation: __________________________

Telephone # (   )___________ Fax # (   )______________

Email Address______________________

Address____________________________________________________

City, State, Zip, ______________________________________________

Illustration to be received by: Mail____ Fax____ Email____

Client Name: __________________________________________

D.O.B. ________________________

Sex: □ M □ F Tobacco Use: □ Y □ N State: _______ Net Annual Income: _______

Occupation_________________________________________________

Job Description/Duties_________________________________

Business Owner: □ Y □ N; C-Corp: □ Y □ N; S-Corp: __ Y __N

# of Employees_____  Years in business______

Group LTD in force: □ Y □ N Monthly Amount: $___________ 60% or 67% (circle one)

Individual coverage in force: □ Y □ N Monthly Amount: $_________ To remain in Force? □ Y □ N

Who will pay the premium: □ Employee Pay □ Employer Pay

Monthly Benefit: $__________________

Elimination Period: □14 □30 □60 □90 □180 □365 □730 Days
Benefit Period: □6 Months □1 Year □2 Years □5 Years □To Age 65 □66/67 □Lifetime
Discount: □Association □Multilife □Double Annual Premium
Benefit Riders:
□Residual □COLA □Non-Can □Own Occ. □Future Purchase Option □Automatic Increase

□Return of Premium □Activities of Daily Living □Catastrophic Rider □Social Insurance

Medical History________________________________________

COMMENTS: ____________________________________________________

____________________________________________________
Please submit the DI Quote information via email:
John C. Massolio III, CLU ChFC
john@brassringfinancial.solutions

888-651-0025

We will provide you the best quotes from the industry’s leading carriers.