Larry Madama & Associates

Due to the complexity of disability insurance proposals, we may need to clarify your responses. As such, please be sure to provide an "accurate" phone number and email address. We do not sell, distribute, spam or solicit your email account, nor give your address to any other party. As such, please provide your fastest email address. Since quality email addresses can accept larger files, we can give you more detailed and helpful information.

This form must be fully completed to receive proposals (no exceptions). It is available in PDF or the electronic format below.

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Producer Information

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Business Phone:

Mobile Phone:

Email Address:

Prospect Information

First Name:

Last Name:

Application State:

Birth Place:

Date of Birth:

MMDDYYYY

Gender:

Male Female

U.S. Citizen:

Yes No

How long has client lived in the U.S.A.

Exact Height:

Feet Inches

Exact Weight:

lbs

Occupation & Title:

Company Name:

Annual Income:

Self Employed?

Yes No

If self employed:

Business Structure

Percent owned:

Years with current employer:

Years of Experience in Your Profession:

Please describe your occupational duties and the percentage of time spent on each duty:

Percent of time client works from home:

Please describe your professional education and/or training:

HAVE YOU (use tab key to type details)

1. Applied for any disability insurance within the last 24 months

Yes No

2. Been declined for any disability insurance in the last 3 years

Yes No

3. Ever collected disability benefits for sickness or injury

Yes No

4. Participated in sky diving, scuba diving, parachuting, racing, mountain climbing, hang gliding, ballooning, rodeos, or competitive skiing

Yes No

5. Ever flown as a pilot, student pilot or crewmember

Yes No

6. Been convicted of a moving traffic violation or had a driver's license revoked or suspended within the past 3 years

Yes No

7. Been convicted or charged with a felony

Yes No

8. In the next year, any intention of traveling or residing outside of the U.S. or Canada

Yes No

9. Do you belong to or intend joining any active or reserve military, naval or aeronautic organization

Yes No

10. Used any form of tobacco or nicotine in the last 12 months

Yes No

WITHIN THE LAST 10 YEARS, HAVE YOU HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING?

11. Disorder of the eyes, ears, nose or throat

Yes No

12. Dizziness, fainting, seizures, headache; speech defect, paralysis, stroke; mental or nervous conditions including anxiety or depression or counseling

Yes No

13. Shortness of breath, persistent hoarsemess or cough, bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder

Yes No

14. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack, or other disorder of the heart or blood vessels

Yes No

15. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, hepatitis, colitis, diverticulitis, hemorrhoids, recurrent indigestion or other disorder of the stomach, intestines, liver or gallbladder

Yes No

16. Sugar, albumin, blood or pus in your urine, venereal disease; stones(s) or other disorder of kidney(s) or bladder

Yes No

17. Diabetes; thyroid, or other endocrine disorders

Yes No

18. Disorder of breasts, reproductive organs, prostate or complications of pregnancy

Yes No

19. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles, bones, spine, back or joints

Yes No

20. Disorder of the skin, lymph glands, cysts, tumors or cancer

Yes No

21. Allergies; anemia or other disorder of the blood

Yes No

22. Have you had any other mental or physical disorders, injuries, sickness or symptoms not asked, which you have been treated for, taken medication for, or for which an ordinarily prudent person would have sought medication, treatment or advice, or counseling during the last 10 years

Yes No

Other than noted above, have you within the past 5 years:

23. Had any check-ups, pap tests, consultations, illness, injury, or surgery; been a patient in a hospital, clinic, sanatorium, or other medical facility; had any EKG, ECG, X-ray or other diagnostic test(s)

Yes No

24. been medically advised to have any diagnostic test, hospitalization, or surgery which is not yet completed

Yes No

Within the past 10 years have you ever:

25. Used marijuana, cocaine, barbiturates, tranquilizers, heroin, LSD, amphetamines, morphine, narcotics or any other drugs, except as legally prescribed by a physician

Yes No

26. Sought or received medical treatment or professional advice, or been arrested for the use of alcohol, cocaine, marijuana, narcotics or any other drugs

Yes No

Other:

27. Use of alcoholic beverages (type & quantity per week)

Yes No

28. Been diagnosed as having AIDS, ARC or HIV

Yes No

29. Are you now under observation or receiving medical treatment

Yes No

30. Are you pregnant, if yest what is your due date

Yes No

31. Have you had a change in weight in the last 12 months, if "yes", what amount gained or lost

Yes No

32. Do you have a doctor appointment scheduled in the next 6 months, if "yes" what is the reason and who is the doctor

Yes No

33. Do you exercise, if "yes" provide details

Yes No

34. Do you take vitamins or any food supplements, if "yes" provide details

Yes No

35. DO YOU HAVE ANY PRIVATE DISABILITY INSURANCE NOW IN FORCE (If "yes", list below)

Yes No

	Insurance Company	Monthly Benefit	Waiting Period	Benefit Period	Will this coverage be cancelled or replaced
Private Plan					Yes No
Private Plan					Yes No
Private Plan					Yes No

36. DO YOU HAVE ANY GROUP DISABILITY INSURANCE NOW IN FORCE (If "yes", list below)

Yes No

	Who pays for the cost of this coverage?	Monthly Benefit (%)	Waiting Period	Benefit Period	Will this coverage be cancelled or replaced
Group Plan					Yes No
Group Plan					Yes No
Group Plan					Yes No

HAVE YOU CONSIDERED THE DIFFERENCE BETWEEN GROUP AND INDIVIDUALLY OWNED DISABILITY COVERAGE?

Group Coverage or Trade Association Coverage	Individually Owned Coverage
Can be cancelled anytime by the employer or the insurance company	Guaranteed renewable to age 65, conditionally renewable for lifetime Noncancelable by the insurance company as long as premiums are paid on time within the grace period
Terminates when you change jobs Terminates when you reduce hours to work part-time Terminates when you are no longer a member	Remains in force when you change jobs or occupations Remains in force regardless of the hours you work Does not require membership
You do not own the policy Policy is owned by the employer or trade association You do not choose the policy provisions or quality	You own the policy You choose the policy provisions and quality level
Definition of disability: During the first 24 month injury or sickness prevents you from performing the duties of your own occupation. After 24 months injury or sickness prevents you from performing the duties of any gainful occupation	Definition of disability: Injury or sickness prevents you from performing the duties of your own occupation
Benefits stop if you are able to earn income from some other occupation	Benefits continue if you are able to earn income from some other occupation Benefits continue if you do earn income from some other occupation
Benefits automatically reduced if you collect from: Workers compensation Social security disability State disability benefits	Benefits not automatically reduced by other sources: You choose whether or not to integrate with these sources at the time you purchase your policy
Benefits received during disability are taxable to you	Benefits received during disability are tax-free.

BUSINESS OVERHEAD EXPENSE INSURANCE

Please answer the following questions:

Note: If you have partners that share these expenses, only include your portion of these expenses which you are responsible for.

How many employees do you have?

How many of them are in your same profession/occupation?

How many partners do you have excluding yourself?

Please "estimate" the following "monthly" expenses:

Covered Business Overhead Expenses	Monthly Amount
Electric Utilities
Gas, oil or propane utilities
Water & sewer utilities
Garbage & waste utilities
Telephone utilities
Wages & salaries for your employees (excluding you)
Cost of employee benefits like health insurance
Janitorial & cleaning services
Laundry & maintenance services
Property insurance
Liability insurance & malpractice insurance
Rent for your building or office space
Principal payments on your mortgage (business premises)
Interest payments on your mortage (business premises)
Realestate taxes on your business premises
Accounting fees
Legal fees
Equipment & furniture leasing payments
Principal payments on business loans or lines of credit
Interest payments on business loans or credit lines
Monthly Combined Expenses

If any of these expenses are reimbursed to you, give complete details below:

Special Instructions or Concerns:

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