Business Underwriters Associates
Disability Insurance Proposal Request
Please fax back to BUA at 330-929-9994
Agent _____________________________ Date __________________________
_____________________________
_____________________________ Phone _________________________
Fax _________________________
Email __________________________
Client
___________________________________________ M F Age __________________ S NS
Ht ______________ Wt _____________
Occupation _________________________________________ Occupation Class _____________
Annual Income ______________________________________ State ______________
Medical Conditions/ Medications________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Benefits
Monthly Benefit Maximum 50% 25% Other
Elimination Period 30 Days 60 Days 90 Days Other
Benefit Period 2 Years 5 Years To Age 65 Other
Other Disabilty Coverage No Yes Group Amount
Optional Benefits Cost of Living Retroactive Residual Return of Premium
FPO
Plan Types
Guaranteed
Renewable $
Non­ Cancellable $
Business Overhead
Expense $
Special Risk $
Send: Quote _________
Licensing _________
Brochure _________
Application _________
Mail to Agent: YES
FAX to Agent: YES
Email to Agent: YES