Guardian Disability Insurance Brokerage

In order to obtain a quote please fill out the following form and click "SUBMIT" below. We will automatically receive your information and begin working on your quote immediately. You have the option to request the quote via fax, or through the mail. We sincerely appreciate the opportunity to write more business with you. If you would like to call us to discuss a quote, our number is 240-683-9700 in Rockville .

Your Information
Your Name:
Your Company:
Your Address:
Your City:
Your State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
Your Zip:
Your Phone Number:
Your Fax Number:
Your E-mail Address:

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Policy Information
Company Name:
Address:
Nature of Business:
Years Business:
Entity:	C-Corp S-Corp Partnership LLC LLP Sole Prop
Number of Employees:	Full Time Part Time

Number in Eligible Group:

Nature of Eligible Group:

All Other (describe-execs, managers and key employees)

Is this company already a client?

No Yes (describe other plans you have put in place)

Describe employee turnover in last 2 years:
With respect to eligible group?
Describe business stability in last 3 years (i.e.: growth of company, profitability, layoff history, etc.):
Describe any known medical histories (attach page if needed)

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Competition
Is there competition on this policy?	No    Yes
If yes, name of carrier:
Type of product: (individual, group, association, etc.)
Nature of offer: (any guarantees, maximum coverage, etc)

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Existing Coverage
Group STD:	Carrier: Waiting Period Benefit Period

	Formula:	%  Base Only to a / month maximum %  Base + Bonus to a / month maximum
	Premium paid by:	% Employer % Employee

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Group LTD:

Carrier: Waiting Period Benefit Period

	Formula:	%  Base Only to a / month maximum %  Base + Bonus to a / month maximum
	Premium paid by:	% Employer % Employee

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Individual Employer sponsored coverage:

Carrier: Waiting Period Benefit Period

	Benefit Amount:	$  / month maximum
	Premium paid by:	% Employer % Employee Payroll Deduction

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Underwriting Request
Name of Product applied for:
Premium paid by:	% Employer % Employee

Coverage will:

Supplement Replace

STD LTD Individual

Contract to Quote:
Effective Date:
Start Date:
Enrollment Period:	Weeks Months
Who will do the field underwriting on the policy?	Self Self and others (describe)
If employees are not local, how will applications be taken?
Describe your marketing plan:
Billing:	New List Bill Existing List Bill Direct Bill Other

Additional Policy Info:

Send Illustration Via:	E-Mail     Mail     Fax