Proposal Request for Employee Benefit Advisors

Select Service Model
Choose One*
- Classical
- Exclusive - 15%
Click here to view Classical and Exclusive services comparison
Illustration, presentation, and implementation assistance
Direct client consultation for a 15% commissions split

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Advisor Information
Full Name*
Email*
Additional Email

Include if you would like us to CC an additional contact on all case correspondence
Are you new to working with Secura Consultants?*
- Yes
- No
We reach out to all new advisors to learn more about their practice and discuss how we can best align our services
Company Name*
Phone*
When are you meeting with your client?

Knowing your meeting date allows us to prioritize requests and make sure you have what you need in a timely manner

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Coverage Type
Disability Solutions
- Individual Disability
- Business Overhead Expense
- Key Person Disability
- Disability Buyout/Buy-Sell
- Group/Ancillary Benefits
Individual Disability: replaces a portion of lost income in the event the insured is sick or hurt and cannot work, or cannot work as effectively as before
Business Overhead Expense: reimburses the insured business owner during a disability for covered business expenses that are incurred in the day to day operation of the business
Key Person: pays the business for financial loss during a key person's disability until recovery or a suitable replacement can be found
Disability Buyout/Buy-Sell: pays to a corporation or co-owner either a lump-sum or installment payments upon disability of an insured owner to provide the necessary funds to buy-out the business interest of the disabled owner
Group: allows employers to offer long term disability, short term disability, life insurance, dental, and vision insurance to their employees while keeping premiums affordable
Is this a multi-life opportunity?*
- Yes
- No
If yes, we will look for any possible guaranteed issue solutions and/or discounts.
Multi-life cases require a completed census along with additional company information. This information allows us to find the best solutions for your client.

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Client Information
Full Name*

This allows us to better track your client opportunities in our system
Date of Birth
MM slash DD slash YYYY

Insurance rates are formulated using age
Gender*
- Male
- Female
- Other
Insurance rates are formulated by gender
Gender
State of Residence*
Insurance rates are state specific
Where is the client's primary residence?
Client Also Applying for Life Insurance or Has in the Past 6 Months
- Yes
- No
If so, we may be able to coordinate some aspects of underwriting to make for a more streamlined process

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CLICK HERE to download our health questionnaire.

Health Information
Tobacco Used*
- Yes
- No
- Quit
Insurance rates are formulated by tobacco usage. This includes chewing tobacco, snuff, cigars, etc.
Date Last Used (If Known)

MM/DD/YYYY
Are there any known health concerns?*
- Yes
- No
Knowing this information before a quote is delivered allows us to discuss options with our underwriters and present a plan that is both realistic and still attractive for your client. Presenting a realistic plan from the initial stages of case development lessens the risk of the client opting out of the disability insurance plan.
Details
List any diagnoses, medications, or treatments you are aware of. Also note any drug usage, criminal activity, or other avocations that may impact underwriting. We will follow up with a health questionnaire for additional details.
Knowing this information before a quote is delivered allows us to discuss options with our underwriters and present a plan that is both realistic and still attractive for your client. Presenting a realistic plan from the initial stages of case development lessens the risk of the client opting out of the disability insurance plan.

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Discussion Questions
State of Business Headquarters*
Some carriers allow us to situs to the headquarter state, simplifying the implementation process
Location of Business Headquarters
When would the group like to implement this program?

This helps us to determine the targeted coverage effective date. We recommend that this is off-cycle from their other benefit enrollments.
Is there any coverage inforce?
This coverage will coordinate with any inforce disability insurance coverage
Has a premium budget been discussed?
- Yes
- No
Knowing a reasonable premium target allows us to create a policy that fits the client's needs and budget
What is the annual premium target?

Knowing a reasonable premium target allows us to create a policy that fits the client's needs and budget
When will you be meeting with the group?

Knowing your meeting date allows us to prioritize requests and make sure you have what you need in a timely manner

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Lines of Coverage
Lines of Coverage Requested*
- Short Term Disability
- Long Term Disability
- Life
- Dental
- Vision
Additional Information
Do you have a preferred plan design in mind?*
- Yes
- No, I'd like your team to make a recommendation.
Individual Preferred Plan Design
Elimination Period, Benefit Period, Replacement %, Full Mental Nervous Protection, COLA, Catastrophic
Overhead Expense Preferred Plan Design
Elimination Period, Benefit Period, Future Increase Options, Residual, Loan Protection
Key Person Preferred Plan Design
Elimination Period, Benefit Period, Lump Sum vs. Monthly Benefit Payments, Benefit Amount (1x Income)
Disability Buyout Preferred Plan Design
Elimination Period, Benefit Period, Lump Sum vs. Monthly Benefit Payments
The insurance payment will match the buy sell agreement at claim time. It is important to finalize the agreement prior to purchasing the insurance coverage. A buy-sell agreement is not required in most states in order to purchase disability buyout insurance, but one must be in place at the time of a disability claim.
Group Preferred Plan Design
Additional Notes
Upload Documents
Please attach a company census, current group coverage certificate, and any other relevant documentation.
Census*
Max. file size: 128 MB.
CLICK HERE to download our census template.
Utilize our census template with helpful comments explaining why each field is important.
Current Group Certificate
Max. file size: 128 MB.
It is necessary for us to know the details of the group’s current disability program in order to provide a complementary individual program
Other
Drop files here or

Max. file size: 128 MB.

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Additional Information
Do you have a preferred plan design in mind?*
- Yes
- No, I'd like your team to make a recommendation.
Individual Preferred Plan Design
Elimination Period, Benefit Period, Benefit Amount, Definition of Disability, Additional Riders (COLA, Catastrophic, Future Increase Options)
Overhead Expense Preferred Plan Design
Elimination Period, Benefit Period, Benefit Amount, Future Increase Options, Residual, Loan Protection
Key Person Preferred Plan Design
Elimination Period, Benefit Period, Lump Sum vs. Monthly Benefit Payments, Benefit Amount (1x Income)
Disability Buyout Preferred Plan Design
Elimination Period, Benefit Period, Lump Sum vs. Monthly Benefit Payments
The insurance payment will match the buy sell agreement at claim time. It is important to finalize the agreement prior to purchasing the insurance coverage. A buy-sell agreement is not required in most states in order to purchase disability buyout insurance, but one must be in place at the time of a disability claim.
Additional Notes
Upload Documents
Please attach financial statements, existing policies, medical records, or any other relevant documentation.
File
Drop files here or

Max. file size: 128 MB.
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Step 1 of 10

Select Service Model

Advisor Information

Coverage Type

Client Information

Employment Information

Client Compensation & Household Expenses

Client Inforce Coverage

Health Information

Discussion Questions

Lines of Coverage

Additional Information

Upload Documents

Additional Information

Upload Documents