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This information is for the exclusive, private use of Disability Insurance Resource Center and will not be sold, distributed or otherwise disseminated and will be classified as confidential. Please take a few minutes of your valuable time to complete this form as accurately as possible. While it may look daunting, it is necessary in order to provide a quote that accurately reflects the risk.

Name:

Email:

Street:

Apt/Suite:

City:

State:

Zip:

Home
Phone:

Work Phone:

time to call

Gender:

Date of Birth

Height:

Weight:

Tobacco?

Occupation & designation	Gov't Worker:	If yes, Since (year)
Briefly describe your duties*	Health Issues:
	If Other, Explain (medications etc):

*You may select more than one duty by holding down CTRL and clicking applicable duties. In the case of medical professionals; describe your work environment, office/hospital, designation and medical specialty...i.e. surgeon, internal medicine, etc. Please use the "If Other" area to do this.

Earned Income: Unearned Income:
Employee Current Annual Salary(W2):	or Self Employed Net Profit (1099) (Use Most Current Filed Tax Year)	(eg. retirement, rental property etc)

Existing Current Coverage (already in force):
Want to replace? Yes No
Type	Elimination Period	Benefit Period	Monthly Benefit Amount


Desired Coverage:
*Refer to the Needs Calculator to determine how much of a monthly benefit is needed.	Elimination Period	Benefit Period	Monthly Benefit Amount*

Please select time periods from the drop down menus above.

VERY IMPORTANT - PLEASE READ INSTRUCTIONS:
(Please print out this guide to use while completing your request for quote.)

After reading the glossary of terms, select your desired coverage from the above choices. Additional insight, beyond what the glossary reveals, can be obtained by reading our industry wide published article on "How to select the Ideal Disability Policy" by clicking "Ideal Policy article" on the tool bar under our logo. For your information, typical coverage can cost between 2-3% of income for males and 3-4% of income for females and consists of a 90 day elimination period, a benefit period to age 65 (however, not everyone can get a benefit period to 65 due to occupation or health) plus all applicable options and the maximum benefit amount allowed (usually between 50-60% of your income) If these approximate costs are acceptable, enter these components in the applicable fields above. If you feel the costs might be too high, you can select other configurations which will lower the cost, or give us your monthly premium budget and we'll create a configuration to match that amount. Enter your budget amount here: (how much you want to spend).
Note: If for some reason, when you receive the proposal, and it doesn't exactly meet your requirements, please do not hesitate to contact us for a re-run.

Glossary of Terms

Elimination Period- This is like any other deductible, it is the number of days you will be "self-insured" while disabled; meaning, no benefits will be paid for that period of time. You will note that when your proposal arrives, we have shown a 90 day elimination period, which is the most frequently selected and costs approximately half of the 30 day (which is available for most benefit periods). The proposal will also give you alternate elimination periods for most benefit periods; (how long you will be paid).

Benefit Period- This is the length of time you will be paid for a disability (after the elimination period has been satisfied). The longer the benefit period (number of years you'll have a guaranteed paycheck) the higher the cost. Conversely, the shorter the benefit period (eg.2 yrs), the lower the cost. The proposal will automatically show alternates to the one selected.

Benefit Amount- This is the amount of your "tax free guaranteed paycheck" that will be paid to you each month (after the elimination period has been satisfied) for the duration of the benefit period you have selected. Typically, as previously mentioned, you are eligible for between 50-60% of your income, less benefits already in force. Please enter "Max" in this field if you want the most you are eligible for, or a specific amount, if you want less than what the "max" will allow. When you receive the proposal, you will be able to compute a premium for any other benefit amount, by dividing the premium by the benefit amount. This will create a per $100 rate. Multiply the benefit amount you wish by this rate. (e.g. $2350/month means you'll multiply this per $100 rate by 23.5)

Monthly Premium/Budget- This is the monthly premium you wish to spend each month. This amount will override the premium (cost) developed by the computer based on your selected desired coverage and also will change the desired coverage configuration you have chosen to a longer elimination period, shorter benefit period or a lower benefit amount to match your budget. If you want to see two proposals, one with your budget constraints and one without, please say so in the comments box!

Please make sure to complete all fields for best results.

Call or write today for more information

	Disability Insurance Resource Center 7405 Wadi Musa Drive N.E., Albuquerque, New Mexico 87122 PO Box 21243 Albuquerque, New Mexico 87154	Nat'l Toll Free: (800) 551-6211 Local (NM): (505) 299-5566 Fax: (505) 299-7788 Cell: 703-615-4747 info@di-resource-center.com


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