A Easy Fact Finder - Generic - AFF2019SD REF2019HHG BR2019PP DIBUNK201911 1DIQ2019EEW 1CLFF2019FF FFINTERNAL2019VV

Data from Life Insurance Quote Tool

Personal Information

(no initials, type NONE if applicable)

Personal Questions

Home Address

Mailing Address

Employment Information

Please be specific if within last 2 years, otherwise an estimate is fine
Please be specific and list specific manual duties that are performed on a daily basis.
We are looking to use the Unisex priced Multi-Life discount program from Principal for you if possible. This is the largest discount in terms of net percentage of premium that exists in the disability insurance market today. It is not available to all but we will try to get it for you.

IMPORTANT: Principal requires us to submit the application to them along with the following if we want to have the discount honored when it is approved:

FEIN (Federal Employer Identification Number) - This can usually be found on a W2. It can also be obtained from someone at your company. It is actually available publicly so let us know if you cannot find it. We can attempt to search for it.

Employer Name
Employer Address

The FEIN is not required in this form to submit it. We understand that you might need to look it up so feel free to send that along after this easy fact finder is done. You will also get an automated email from us that you can reply to with the information that we need for the discount.

include approximate dates and outcomes

Carrier Specific Questions - Guardian DI

Carrier Specific Questions - John Hancock

Beneficiary Details

Note: beneficiaries and percentages can be updated or changed any time you like once a policy is in force

Information for in force life insurance

Policy Design - Life

Policy Design - Disability

Increase occurs on the anniversary of each year while disabled

Future Increase Options - Policy Details

Drop a file here or click to upload Choose File
Maximum upload size: 157.29MB
Drop a file here or click to upload Choose File
Maximum upload size: 157.29MB
Drop a file here or click to upload Choose File
Maximum upload size: 157.29MB

Replacement Details - Disability

If you are replacing another disability insurance policy, there will be additional forms that will need to be signed.

Premium Payor Details

Please ask your employer how they plan to treat the payments that are made on your behalf

Financial Information

NOTE: Feel free to send along specific line item expenses after you complete the initial application
Drop a file here or click to upload Choose File
Maximum upload size: 157.29MB
We commonly run multiple proposals and designs for disability insurance. This field can help us all to quickly identify the specific plan that you are interested in.

By signing below you are attesting that the information you have furnished is accurate and complete. This fact finding form is intended only as a tool to collect information to assist the agent and client to begin the application process with your desired insurance company for the insurance product stated in your state of residence. Information is never sold to 3rd parties or utilized beyond this purpose. Joseph Capone and Richard Warren, Jr. are insurance licensed in all 50 states and Washington, D.C. This form is not an application for insurance and in no way is this form a solicitation for insurance. Each company ultimately has its' own application forms. We will work with the client to submit a formal application for insurance.

By signing below you are attesting that the information you have furnished is accurate and complete. This fact finding form is intended only as a tool to collect information to assist the agent and client to begin the application process with your desired insurance company for the insurance product stated in your state of residence. Information is never sold to 3rd parties or utilized beyond this purpose. This form is not an application for insurance and in no way is this form a solicitation for insurance. Each company ultimately has its' own application forms. We will work with the client to submit a formal application for insurance.

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