Disability Income Data Input
Client Information
Client Info Spouse Info
Courtesy Title
First Name
Last Name
Birthdate (mm-dd-yyyy)
Occupation
Employer
Street Address
Street Address - additional
City
State
Zip Code
Phone
Email Address
Marital Status
+ Income Detail
Client Info Spouse Info
Annual Income
Pay Increases
Desired Retirement Age
+ Assets
Description Estimated Value ($) Ownership Type
1
2
3
4
5
6
7
8
9
10
+ Pension
Client Info Spouse Info
Annual (spouse) pension if you were to be disabled ($)
Adjust pension for inflation?
Pension Begin Age
+ Dependent Information
Name Birthdate (mm-dd-yyyy) Description Annual Cost Set aside (taxable) Set aside (529) % You Pay Starting age Years needed
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2
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5
+ Disability Insurance
Company Annual premium ($) Insured party Monthly Benefit ($) Waiting Period (days) Benefit Per. (years) Maximum Age (if any) Indexed with inflation? (Y/N)
1
2
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4
+ Disability Income Needs
Initial spending ($) For how long? (years) Subsequent spending ($) For how long? (years)
Annual spending if client disabled
Annual spending if spouse disabled
+ Rate Assumptions
Portfolio before-tax return pre-retirement
Average tax bracket pre-retirement
Estimated Inflation Rate (%)
If client were to become disabled, how much (if any) would the spouses personal earned income change from the current level? (allow for negative (-) values)
If spouse were to become disabled, how much (if any) would the clients personal earned income change from the current level? (allow for negative (-) values)