1. Personal
    Information
  2. Employment
    Details
  3. Requested
    Coverage
  4. Existing
    Coverage
  5. Medical
    History
  6. Review
    & Submit
Personal Information
Questions? Fortify Insurance Group
phone: 203-226-4077
email: info@fortifyinsurance.com

Gender
Premium rates are partly based on gender.
Note: Female rates are higher than male rates so be sure to list the name of your Employer to see if special discounting may be available!

Male Female

First Name
We don't really need the clients name ... but it is nice (and helps us keep track of the quotes).
Please know that your clients' personal information is sacred to us and will not be shared with anyone

Last Name

Birthday
Premiums rates are partly based on the clients age.
Most disability insurance carriers calculate premiums based on "actual age" while many Life Insurance carriers calculate premiums based on "nearest age"

State of Residence
Premiums are also based on your state of residence.

Phone Number

Check here if you would like the Disability Analyzer texted to you

We will not call you or share your contact information with anyone unless you give us permission to do so.

Employment Information
Questions? Fortify Insurance Group
phone: 203-226-4077
email: info@fortifyinsurance.com

Name of Employer
Fortify Insurance Group has access to many special Discount Programs.
Note: very often we can offer special discounts based on Employer, Residency/Fellowship Program, Hospital, or Association.

Base Salary
Why do we ask this?
Disability Income Insurance maximum benefits are based off of income.

Bonus Income
Often Bonus & Commission income is not covered under Group LTD policies
Providing this information can help us maximize coverage for your client

Business Owner
As a Business Owner your client may be eligible for policy upgrades based on the information provided.
Note: This is a great way to save your client money on this valuable protection!

No Yes
Number of Years
Number of Employees
Check here if you are interested in learning about ways to protect your business

Occupation
In addition to state of residence and age, premiums are also based on your current occupation.

Do you work at least 30hrs/week?
Most Disability Income policies require that you client is working at least 30 hours per week but Fortify also has options for those working on a part-time basis

Yes No
Number of Hours:
[Error, check internet connection]
Requested Coverage
Questions? Fortify Insurance Group
phone: 203-226-4077
email: info@fortifyinsurance.com

I want quotes for Disability Insurance Coverage:

No Yes

Individual Disability Insurance?

No Yes

Monthly Benefit

Elimination Period

Benefit Period

Additional Case Notes or Special Instructions

Disability Business Overhead Expense?

No Yes

Monthly Benefit

Elimination Period

Benefit Period

Loan Indemnification Rider?

No Rider Yes

Amount of Loan  Loan Effective Date

Monthly Loan Payment  Loan Termination Date

Additional Case Notes or Special Instructions

Keyperson Disability?

No Yes

Monthly Benefit

Elimination Period

Additional Case Notes or Special Instructions

BuySell Disability?

No Yes

Client’s Approximate Business Value

Benefit Requested

Elimination Period

Plan Design

Lump Sum Only Monthly Payment Only Combination

Monthly Benefit Period

Additional Case Notes or Special Instructions

I want quotes for Life Insurance Coverage:

No Yes

Term Life Insurance?

No Yes

Presumed Risk Class

Rated? Not Rated Rated

Death Benefit

Term of Insurance

Riders

Waiver of Premium Return of Premium Child Rider

Additional Case Notes or Special Instructions

Guaranteed Universal Life?

No Yes

Presumed Risk Class

Rated? Not Rated Rated

Death Benefit

Years to Pay Premium

Riders

Waiver of Premium Chronic/LTC Rider

Additional Case Notes or Special Instructions

Indexed Universal Life?

No Yes

Presumed Risk Class

Rated? Not Rated Rated

Death Benefit

Years to Pay Premium

Indexing Strategy

S&P 500 Global Fixed Account

Riders

Waiver of Premium Chronic/LTC Rider

Additional Case Notes or Special Instructions

Whole Life?

No Yes

Presumed Risk Class

Rated? Not Rated Rated

Death Benefit

Years to Pay Premium

Riders

Waiver of Premium Chronic/LTC Rider

Additional Case Notes or Special Instructions

Existing Coverage
Questions? Fortify Insurance Group
phone: 203-226-4077
email: info@fortifyinsurance.com

Do you have any inforce Disability Insurance Coverage?

No Yes

Group LTD through Employer?

No Yes

Who Pays the premiums?

Employer Me

What are the coverage parameters?

Percent of income replacement to maximum benefit of

Individual / Association Coverage?

No Yes

Name of Insurer (if known)

What are the coverage parameters?

Monthly benefit amount

Elimination Period

Benefit Period

Additional Individual Policies?

No Yes

Name of Insurer (if known)

What are the coverage parameters?

Monthly benefit amount

Elimination Period

Benefit Period

Do you have any inforce Life Insurance Coverage?

No Yes

Individual Coverage?

No Yes

Name of Insurer (if known)

Insurance Type

Date of Issue

Death Benefit

Cash Value

Additional Individual Policies?

No Yes

Additional Policy #1

Name of Insurer (if known)

Insurance Type

Date of Issue

Death Benefit

Cash Value


Additional Policy #2

Name of Insurer (if known)

Insurance Type

Date of Issue

Death Benefit

Cash Value


Additional Policy #3

Name of Insurer (if known)

Insurance Type

Date of Issue

Death Benefit

Cash Value


Additional Policy #4

Name of Insurer (if known)

Insurance Type

Date of Issue

Death Benefit

Cash Value


Medical History
Questions? Fortify Insurance Group
phone: 203-226-4077
email: info@fortifyinsurance.com

Height
Height and weight can be a factor in the rate as Insurance carriers believe elevated weight can increase the risk of future disability.

Normal

Weight
Height and weight can be a factor in the rate as Insurance carriers believe elevated weight can increase the risk of future disability.

Normal

Do you smoke?

No Yes
Type

Notable Medical History or Other Information

Please include current prescriptions, previous surgery, recent symptoms treated by a physician, or any other information that will help us provide you with an accurate analysis of the best available coverage at the lowest possible premium.

*All information you provide Fortify Insurance Group is kept confidential and ONLY used for the purposes of securing an accurate proposal.

Review & Submit
Questions? Fortify Insurance Group
phone: 203-226-4077
email: info@fortifyinsurance.com
Please take a moment to review the information below before submitting your request.
Agent Information

Name:

Email:

 

Client Information

Name:

DOB:

Salary:

Gender:

Height:

Bonus:

State:

Weight:

Contact Information

Phone:

Tobacco Use

Current Use:

Type:

Medical History

Details:

 
Employment

Employer:

Hrs/Wk:

Job Title:

Details:

Business Owner:

Yrs Owned:

# F/T EEs:

Requested Quotes

Disability Insurance

Individual Disability Insurance?

Disability Business Overhead Expense?

Keyperson Disability?

BuySell Disability?

Life Insurance

Term Life Insurance?

Guaranteed Universal Life?

Indexed Universal Life?

Whole Life?

Existing Coverage

Disability Insurance

Group LTD?

Individual/Association?

Other Policies?

Life Insurance

Individual?

Other Policies?

All information you provide is kept confidential and ONLY used for the purposes of securing an accurate proposal.

SUCCESS!
Questions? Fortify Insurance Group
phone: 203-226-4077
email: info@fortifyinsurance.com

Your request has been received by Fortify Insurance Group and our Illustrations team will begin processing right away.

Generally quotes are processed within 24 hours from receipt but if there is specific medical or other case details that require special underwriting consideration the turnaround could take a longer.

If additional information is needed a Brokerage Consultant will get in touch with you and you can check status of your request by calling 203-226-4077 or emailing illustrations@fortifyinsurance.com

Thanks for your support and we look forward to assisting you.


- Your friends at Fortify Insurance Group.

powered by Fortify Insurance Group