Kouzmanoff Financial and Insurance Services, Inc.

Applicant Name

Applicant Age

Date of Birth

State where application will be taken

Applicant Gender Male: Female:

Nicotine Used any form of nicotine in past 12 months? Yes: No:

Applicant Occupation

Describe Daily OCC Duties

Is the applicant an employee of School, Federal, State, County, Municipality, or other Government/Public entity? Yes: No:

What percentage of occupational duties are performed at place of residence?

Work in occupation at least 30 hours/week? Yes: No:

Annual Earned Income (after business expenses if self-employed)?

Self Employed ? Yes: No:

If Yes, How Long?

How many full time employees

What type of business entity? Sole Proprietor C Corp Employee S Corp Employee Partnership Other

Any individual disability coverage in force? Yes: No:

If Yes, what is the monthly benefit?

Benefits to be Quoted

What type of Policy? Individual Disability Insurance Business Overhead Expense Business Disability Buyout Other

Elimination Period 30 Days 60 Days 90 Days 180 Days 365 Days 730 Days  

Benefit period 2 Years 5 Years To age 65  

Monthly Benefit: Maximum and or requested?

Optional Benefits to be Quoted

Extended Residual Yes No  

Future Purchase Option Yes No  

COLA Benefits Yes No  

remiums to be paid by Employee Employer  

Prescription Medications: Any taken, if so, what and how much  

Special Health or other underwriting considerations  

Forward Proposal By: Mail Fax Email