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Preferred Method of Proposal Delivery

Email    US Mail    Fax 

Other information necessary to run a proposal:

 Male       Female 

Date of Birth:

Do you smoke? Yes  No

Estimate of personal annual income: $30,000-$50,000

$50,000-$75,000$75,000-$100,000$100,000-$125,000

$125,000-$150,000$150,000-$175,000$175,000+

You can enter your exact income here for complete accuracy if you wish:

Are you a new practicing dentist?  (<1 year) Yes No

Do you own your own practice?  Yes  No

 Do you currently carry a personal disability policy?  Yes No

If yes, company name:

Approximate year purchased:

For Overhead Expense Coverage, please estimate the following:

Monthly Fixed Overhead Expenses: 

For Loan Coverage Policies, estimate the following:

Loan Principal amount:

Term of note in years:   

Please let us know if you would like information on any of  the following products in addition to disability insurance:  Life InsuranceRetirement Planning Overhead Expense coverage Buy-Sell coverage for partnership agreements Loan coverage policy  Retirement Protection Plus

How did you find out about us?