Lanny D. Levin Agency; http://www.levinagency.com - Request a Disability Insurance Quote

...creating legacies, preserving businesses, and rewarding executives...

User ID:
Password:

REQUEST RETIREMENT PROTECTION PLUS PROPOSAL

Fields marked with

are required.

Your Information
Your Name:
Your Company:
Your Address:
Your City:
Your State:
Your Zip:
Your Phone Number:
Your Fax Number:
Your E-mail Address:	E-Mail Me A Copy of This Proposal
Your DI Specialist:

Insured Information
Proposed Insured:
Age or Date of Birth:
State:
Gender:	Male Female
Tobacco User:	None for 1 year or more Cigarettes, Pipe or Chew Cigar Only / How Often?

Occupation:

Past Year Income:

If Self-Employed, net Schedule C income AFTER business expenses:	$
If Salaried, salary plus bonus:	$
If Partner or S Corp principal, income from K-1:	$

Current Personal Individual Monthly Coverage:	$
Employer Paid Group:	$
Personally Paid Group:	$

Retirement Plan Contribution:

Employee/Insured's Annual Retirement Plan Contribution:	$
Employer's Annual Retirement Plan Contribution:	$

Monthly Benefit Desired:

Maximum Available

Request specific amount: $

Benefit Period:

Elimination Period:

Available Riders:

COLA	3% 6%
Future Increase Option	Maximum Specify $

Additional Case Info:

Is this part of a multi-life Qualified Sick Pay Plan?	Yes No
Send Illustration Via:	E-Mail Fax Mail

1751 lake cook road, suite 350, deerfield, illinois 60015