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Disability Insurance Quote Request

Contact (808) 536-1933 for immediate questions, Monday - Friday, 8:00 am - 4:30 pm, excluding office holidays.

Agent Information

Agent(Required)

First Last

Telephone

Email(Required)

Contact

Affiliation

Client Information

Prospect Name

First Last

Gender

Male

Female

Date of Birth

Month

Day

Year

Is he/she a United States citizen?

Yes

No

State of Residence

State written in

Tobacco use?

Yes

No

Occupation (Be specific)

Work 30 or more hours a week?

Yes

No

Salary, or if Self-Employed then Net Income From Business

Specific Duties (Time spent doing each)

Is Client:

Salary Employee

Sole Proprietorship

LLC/Partnership

S-Corp Owner

C-Corp Owner

If business owner, length of time owned?

Number of employees

Is there other coverage in force?

Yes

No

Group LTD $

Individual DI $

Medical Conditions:

Carrier Preference

Benefits to Quote: Disability Insurance

Monthly Benefit or Maximum Available?

Monthly Benefit Amount

Elimination Period

30 days

60 days

90 days

180 days

365 days

730 days

Benefit Period

2 years

5 years

To Age 65

To Age 67

To Age 70

Optional Benefits

Own Occupation

Residual

COLA

Future Purchase

Social Security Rider

Show All

Benefits to Quote: Business Overhead Expense (BOE)

Monthly Benefit or Maximum Available?

Monthly Benefit Amount

Elimination Period

30 days

60 days

90 days

Benefit Period

12 months

18 months

24 months

Optional Benefits

Residual

Future Purchase

Salary of Replacement

Show All

Benefits to Quote: Disability Buy-Out (DBO)

Monthly Benefit or Lump Sum Benefit?

Monthly Benefit Amount

Lump Sum Benefit

Total Coverage Desired

Elimination Period

12 months

18 months

24 months

Benefit Period

Lump Sum

24 months

36 months

60 months

Additional Information

Any additional comments or considerations

Δ

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Occidental Underwriters of Hawaii, Ltd.
1163 South Beretania Street
Honolulu, Hawaii 96814
Phone: (808) 536-1933
Fax: (808) 527-8810

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