CPS-Reliable Financial Group
Experts in Business, Estate and Personal Life Planning
A CPS Insurance Services, Inc. Affiliated Office
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Broker Information
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Client Information
(2 Lives Required)
*
Client #1:
*
Date of Birth:
*
Sex:
M
F
*
Smoker:
Yes
No
*
Annual Income:
*
Job Title:
*
Does Client work at home?
Yes
No
If yes, what %:
*
Job Duties:
*
% Owned:
Client #2
:
Date of Birth:
Sex:
M
F
Smoker:
Non Smoker
Smoker
Annual Income:
Job Title:
Does Client work at home?
Yes
No
If yes, what %:
Job Duties:
% Owned:
Client #3:
Date of Birth:
Sex:
M
F
Smoker:
Non Smoker
Smoker
Annual Income:
Job Title:
Does Client work at home?
Yes
No
If yes, what %:
Job Duties:
% Owned:
Client #4:
Date of Birth:
Sex:
M
F
Smoker:
Non Smoker
Smoker
Annual Income:
Job Title:
Does Client work at home?
Yes
No
If yes, what %:
Job Duties:
% Owned:
Plan Design
*
Approximate Business Value:
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Elimination Period:
365 days
540 days
730 days
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Benefit Period:
2 years
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(For maximum benefit amount, type
"max"
in field)
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