

Contact Information
Name
Address
City
State
Zip
Phone
Email

Personal Inforamation
Gender	Male Female
Date of Birth
Height
Weight

Tell Us About Your Work
What is your occupation?
Describe your daily duties

Do you own a business?	Yes No
Estimate your current monthly income
Is disability insurance part of your benefit package?	Yes No

Policy Information
How much of your income do you want disability insurance to replace?
40% 50% 60% 70%
If you become disabled, what's your desired waiting period before benefits begin?
30 days 60 days 90 days 180 days
If you become disabled, how long do you want to be eligible for benefits?
2 years 5 years 10 years until 65

Additional Considerations
Are you a tobacco user?	Yes No
How would you describe your health?	Excellent Very Good Good Poor
Any additional information to consider as we process your request?

Securities and Advisory Services offered through Hornor, Townsend & Kent, INC. (HTK), Member FINRA/SIPC, Registered Investment Advisor 1475 S. State College Blvd., Suite 114, Anaheim, CA 92806