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CPS Horizon Financial - Insuring Divorce Settlements

Your premium quote, an application and a policy highlights document will be emailed to you within 1-2 business days. A DSI Advisor will follow up with you shortly thereafter to confirm you received the information and address any questions.

*Denotes Required Fields
Personal Details of Person Needing Insurance
First Name*:
Last Name*:
Gender*:	Male Female
State*:	Select State ALASKA ALABAMA ARKANSAS ARIZONA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA GEORGIA HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING
Date of Birth*:	(mm/dd/yyyy)
Business Entity:	Select Employee/Non-owner C-Corp Partnership S-Corp Sole Proprietor
Occupation/Duties*:
Net Income*:	$ Net Income — If you are an employee this is your W-2 wage.  If you own a corporation, use gross revenues minus business expenses.  Net income, not gross, is used to determine how much monthly benefit you may qualify for.
Contact Details
First Name*:
Last Name*:
Phone Number*:
E-mail*:
Health History
In the last 12 months have you or the client used any tobacco products?
	Yes No
In the past 6 months have you or the client:
Missed 3 consecutive days of work due to medical reasons?
	Yes No
Been partially disabled, hospitalized or homebound?
	Yes No
Collected or applied for disability income benefits?
	Yes No
Have you been treated for or diagnosed with any of the following conditions: HIV, Stroke, MS, Diabetes, heart or circulatory disease, Parkinson's disease, and/or a condition that could lead to blindness?
	Yes No
If you answered yes to any of the Health History questions, please provide details:
Current Disability Income Coverage
Do you currently have any Disability Income coverage in force?
	Yes No
Policy 1
Benefit:	$
Type:	Individual/Association Group
Policy 2
Benefit:	$
Type:	Individual/Association Group
If you have any additional goals, comments or concerns, please let us know.
Notes:
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