PIA Trust Products and Services - Long Term Disability Income Insurance Individual Census Form


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Long Term Disability Income Insurance

Individual Census Form
This is not an application for insurance. Please submit a separate census form for each person requesting a proposal.
Name
Gender	Male Female
Agency Name
Address
City		State	Zip Code
Phone Number
Fax Number
Number of hours worked per week	(Must work at least 30 hours per week to be eligible)
Date of Birth
Elimination Period Options:	90 days 180 days
Benefit Periods:	2 yrs. 5 yrs. To age 65
Gross Annual Income	(This includes any salary, wages, commissions, bonuses, and fees regularly earned for services performed by the insured)
Monthly Benefit Amount	(Benefit not to exceed 60% of Gross Annual Income to a maximum of $8,000 per month)
Optional Benefits
COLA (Cost of Living Adjustment) for Basic Benefit:	Yes No
Monthly Catastrophic Disability:	(Benefit not to exceed 40% of Gross Annual Income to a maximum of $3,200 per month)

Optional Benefits