Fiduciary Intermediary Ltd. - Request an LTD Quote

Today’s Date:

Effective Date:

Company Name:

Nature of Business:

Location (Zip code):

Tier Structure:

Census:

Number of Employees:

Plan Design (Please check all that apply):

Companies:

Principal:

No

Yes

US Life:

No

Yes

Guardian:

No

Yes

Met Life:

No

Yes

Prudential:

No

Yes

Fortis:

No

Yes

Unum:

No

Yes

other:

Benefit Amounts:

Benefit % of Salary:

Pre-Existing Waiting Period:

3 months

6 months

1 year

other:

Current Rate($):

(Please provide current plan design if it differs from requested plan design)

Renewal Rate (if available)($):

Individual to Fax quote to:

Fax Number:

Phone Number: