IDI Quote Request OneSource

Broker Name*

First NameLast Name

Broker Phone Number*

Area CodePhone Number

Broker Email*

Client Name*

First NameLast Name

Gender*

MaleFemale

Resident State*

Application Sign State*

Date of Birth

MonthDayYear

Age

Tobacco or Nicotine Substitute Use?*

YesNo

Type Used

Date Last Used

Height

Weight

Medical History & Medications (please include dates and dosages)

Occupation*

Hours Worked Per Week

Years With Current Employer

Job Duties & Percentage of Time Performing Each Duty

Government Employee*

YesNo

Years of Service

Employed By

1099 Employee*

YesNo

Business Owner*

YesNo

Business Type

% Ownership

Years Owning Business

Number of Full Time Employees

Number of Part Time Employees

Years Working in Industry

% of Time Working from Home

Earned Income Current Year

NET OF BUSINESS EXPENSES

Earned Income Last Year

NET OF BUSINESS EXPENSES

Earned Income 2 Years Ago

NET OF BUSINESS EXPENSES

Any Unearned or Passive Income?

YesNo

Annual Unearned/Passive Income

Type of Coverage Requested

Individual DisabilityOverhead ExpenseBoth

Existing Coverage*

YesNo

Existing Monthly Benefit

Elimination Period

Benefit Period

Is Coverage Being Replaced

YesNo

Need Help Determining Qualified Monthly Expenses?

Yes

You can use this list of typical fixed overhead expenses to help calculate your client's eligible monthly expenses. Please keep in mind that only the owner being quoted's share of the expenses should be used.

Rent

Utilities

Telephone / Internet

Maintenance / Janitorial

Employee Wages

Employment Taxes

Equipment Leases

Accounting, Billing, Collection

Security

Laundry

Depreciation

Property & Liability Insurance

Health Insurance & Benefits

Business Debt Interest

Business Mortgage Interest

Business Property Tax

Malpractice Insurance

Professional Trade / Association Dues

Other Covered Expenses

TOTAL

Items like the owner's salary or that of a partner, travel and entertainment, income taxes, salary of persons generating income for the business, cost of goods, and the mortgage principal payment are NOT typically coverable expenses.

Monthly Expenses

only owner's share is coverable

Monthly Benefit Requested

if requesting maximum, enter MAX

Elimination Period

Benefit Period

Existing Coverage*

YesNo

Existing Group Coverage

YesNo

Premium Paid by

Replacement %

Monthly Cap

Existing Individual Coverage

YesNo

Monthly Benefit

Premium Paid by

Is Coverage Being Replaced

YesNo

Monthly Benefit

(if requesting maximum, type MAX in box)

Elimination Period

Benefit Period

Optional Riders

Additional Comments

Enter the message as it's shown*

Disability Quote Request

Proposal Request Information

Overhead Expense

Individual Disability