Monthly Benefit
Elimination Period 0 days 7 days 14 days 30 days 60 days 90 days 180 days 365 days
Benefit Period MAX 3 mth 6 mth 12 mth 2 yr 5 yr 10 yr to Age 65 to Age 67 to Age 70
Has this request been submitted to carriers in the past 24 months?
No Yes
What was the outcome Approved as Applied Approved Declined Postponed Approved w/ Changes Please provide details below if declined/postponed.
Additional Case Notes or Special Instructions
Elimination Period 30 days 60 days 90 days 180 days
Benefit Period MAX 12 mth 15 mth 18 mth 24 mth 30 mth
Loan Indemnification Rider?
No Rider Yes
Amount of Loan Loan Effective Date
Monthly Loan Payment Loan Termination Date
Elimination Period 90 days 180 days 365 days 730 days
Client’s Approximate Business Value
Benefit Requested
Elimination Period 365 days 540 days 730 days
Plan Design
Lump Sum Only Monthly Payment Only Combination
Monthly Benefit Period MAX 24 mth 36 mth 60 mth
Presumed Risk Class Preferred Plus Preferred Standard Plus Standard
Death Benefit
Term of Insurance 1 year 5 year 10 year 15 year 20 year 25 year 30 year
Riders
Waiver of Premium Return of Premium Child Rider
Years to Pay Premium MAX Single Pay 10 Pay To Age 65
Waiver of Premium Chronic/LTC Rider
Indexing Strategy
S&P 500 Global Fixed Account
Initial Monthly Benefit
Elimination Period 90 days 180 days 365 days
Benefit Period 2 years 3 years 4 years 5 years 6 years 7 years 8 years
Inflation Option 0 % 3 % 4 % 5 %
Illustrate Asset-based LTC Options Yes No
Marital Status
Married Single Other
Details
Premium Pay Options Single Pay 10-Pay All years Maximum
Solve for Single-Premium
1035 Exchange?
No 1035 Yes
1035 Amount
Interested in using Qualified Dollars to fund LTC? Yes No
Name of Annuitant (If other than Insured)
Name of Annuity Owner (If other than Insured)
2nd Annuitant
2nd Annuitant Birthdate
Qualification Type Qualified Non-Qualified
Amount of Annuity
Type of Annuity FIA MYGA FA
Source of Funds (i.e. Non-Qualified, IRA, Annuity)
Period (i.e. 20 with Single Life, 10 with JT Life)
Who Pays the premiums?
Employer Me
What are the coverage parameters?
Percent of income replacement to maximum benefit of
Name of Insurer (if known)
Monthly benefit amount
Elimination Period
Benefit Period
Insurance Type Term GUL IUL Whole
Date of Issue
Cash Value
Additional Policy #1
Additional Policy #2
Additional Policy #3
Additional Policy #4
Any additional notes about inforce coverage
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.
Name:
Meeting:
Email:
Phone:
DOB:
Salary:
Gender:
Height:
Bonus:
State:
Weight:
Current Use:
Type:
Details:
Employer:
Hrs/Wk:
Job Title:
Business Owner:
Yrs Owned:
# F/T EEs:
Individual Disability Insurance?
Disability Business Overhead Expense?
Keyperson Disability?
BuySell Disability?
Term Life Insurance?
Guaranteed Universal Life?
Indexed Universal Life?
Whole Life?
Individual / Association?
Annuity Details
Group LTD?
Individual/Association?
Other Policies?
Individual?
All information you provide is kept confidential and ONLY used for the purposes of securing an accurate proposal.
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.
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