Disability Insurance Illustration Request Form

Search

Home
Quotes
Forms
Case Status
Underwriting
Resources
E-Solutions
Events
Login / Register

Disability Insurance Illustration Request Form

Please complete the information below to receive a Disability Illustration form. The more information, the more accurate illustration can be to policy issue. Depending on the occupation, income and medical history, we may be limited on the available coverage. Based on the information provided, we will select a plan design that best meets your client's needs.

Are you the Agent or an Assistant?*
Please let us know if you are an assistant or the agent for the case.
The Name of the Assistant*

If you are an assistant, please provide your name
Agent First Name*
Agent Last Name*
Agent Phone Number*
State of Residence*
Agent Email Address*
Dixon Wells Office Affiliation (Please Select One)*
Insurance Companies
- Assurity
- Fidelity
- Guardian
- Illinois Mutual
- Lloyds
- Mass Mutual
- Mutual of Omaha
- Principal Financial
- Standard Insurance
Client's Name*
Gender*
Date of Birth*
MM slash DD slash YYYY
Does your Client Use Tobacco?*
Client's Residence State*
Income*
Occupation*
Job Description*
Is Your Client in the Medical Field?
Question for Medical Professionals
Name of College if currently in Med School*
Is Your Client a Business Owner?*
What Type of Industry?*
How Many Employees*
Question if Business Owner
- Sole Proprietor
- Partnership
- C-Corp
- S-Corp or LLC
Questions Business - Net Income*
Years of Employment*
Requested Monthly Benefit
Premium Payment
- Individual
- Business
Elimination Period*
Benefit Period*
Definition of Disability*
Option Benefit1
- Partial
- Residual
- COLA
- Guaranteed Insurability
- Benefit Update
Optional Benefit2
- Catastrophic
- Student Loan Protection
- Retirement Protection
Other Insurance Inforce*
- Individual Coverage
- Group LTD Coverage
- No Other Coverage
Please tell us how much group LTD or individual disability insurance you have in-force?
Coverage amount and type*
How was coverage issued with other carrier?
Previous Insurance Underwriting*
Please provide details of why your client was rated or declined?*
Medical History*
Height*
Weight*
Medications*
Description of Medication*
Mental Health History*
Because you indicated your client has mental and nervous history, can you provide us more details such as the diagnosis of the condition, when the condition began, and current treatment.
Medical Condition Information*
Other Issues that May Impact Underwriting
General Remarks
Dixon Wells Sales Information

Δ

Dixon Wells

Toll-Free: 800-821-7996

Birmingham

2871 Acton Road, Suite 150
Birmingham, AL 35243
Local: 205-879-0583
Fax: 205-871-1551

Nashville

405 A Two Mile Pike
Goodlettsville, TN 37072
Local: 615-859-3752
Fax: 615-859-6952

Charlotte

8008 Corporate Center Dr., Suite 115
Charlotte, NC 28226
Local: 704-364-8080
Fax: 704-364-6610

Philadelphia

Two Bala Plaza, #300
Bala Cynwyd, PA 19004
Local: 610-660-7709
Fax: 610-617-1072

Columbia

PO Box 647
Columbia, SC 29202
Local: 803-799-4523
Fax: 803-256-8181

Richmond

4805 Lake Brook Drive, Suite 102
Glen Allen, VA 23060
Local: 804-285-7110
Fax: 804-285-7794

Columbus

5775 Perimeter Drive, Suite 140
Dublin, OH 43017
Local: 614-718-9887
Fax: 614-718-9903

proud partner agency of

“Securities offered through The Leaders Group, Inc. Member FINRA/SIPC 26 W. Dry Creek Circle, Suite 575, Littleton, CO 80120, 303-797-9080. Dixon Wells is not affiliated with The Leaders Group, Inc.”