Disability Income
Critical Illness
Accident Expense
Hospital Indemnity
Cancer Expense
Whole Life
Term Life
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Add New Agent Name/Address
Name: 
Address Line 1: 
Address Line 2: 
Address Line 3: 
City: 
State: 
Zip Code: 
Phone Number: 
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Confirm Delete
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Disability Income PRO+ Version 2.0.1.27 
Application State: 
California License Number: 
Type:
Group Size:
Employer Name: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip Code: 
Plan:   
Industry Division: 
Classification:   Monthly Benefit Amount: 
Monthly Benefit Amount
Benefit Amount 1
Benefit Amount 2
Benefit Amount 3
Benefit Amount 4
Benefit Amount 5
Benefit Amount 6
Benefit Amount 7
Benefit Amount 8
Benefit Amount 9
Benefit Amount 10
Benefit Amount 11
Benefit Amount 12
Benefit Amount 13
Benefit Amount 14
Benefit Amount 15
Benefit Amount 16
 
Benefit Period: 
Benefit/Elimination Period Combinations
Benefit Period 1 Elimination Period 1
Benefit Period 2 Elimination Period 2
Benefit Period 3 Elimination Period 3
Benefit Period 4 Elimination Period 4
Benefit Period 5 Elimination Period 5
Benefit Period 6 Elimination Period 6
 
 Accident/Sickness Elimination Period: 
 
Riders: 
On-the-Job Accident & Sickness Disability Income Rider
On-the-Job Accident Only Disability Income Rider
Retroactive Injury Benefit Rider
Spouse Accident Only Disability Income Rider
Emergency Accident Rider
Benefit Amount:
Payment Mode: 
   
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Add New Agent Name/Address
Name: 
Address Line 1: 
Address Line 2: 
Address Line 3: 
City: 
State: 
Zip Code: 
Phone Number: 
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Critical Illness PRO+ Version 0.0.0.0 
Application State: 
California License Number: 
Type:
Group Size:
Employer Name: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip Code: 
Employee Benefit Amount: 
Employee Benefit Amount
Benefit Amount 1
Benefit Amount 2
Benefit Amount 3
Benefit Amount 4
Benefit Amount 5
Benefit Amount 6
Benefit Amount 7
Benefit Amount 8
Benefit Amount 9
Benefit Amount 10
 
Spouse Benefit Amount: 
Spouse Benefit Amount
Benefit Amount 1
Benefit Amount 2
Benefit Amount 3
Benefit Amount 4
Benefit Amount 5
Benefit Amount 6
Benefit Amount 7
Benefit Amount 8
Benefit Amount 9
Benefit Amount 10
 
Child Benefit Amount: 
RidersRider Options: 
Payment Mode: 
   
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Add New Agent Name/Address
Name: 
Address Line 1: 
Address Line 2: 
Address Line 3: 
City: 
State: 
Zip Code: 
Phone Number: 
()     - 
Confirm Delete
Are you sure you want to delete this name/address?
Accident Expense PRO+ Version 0.0.0.0 
Application State: 
California License Number: 
Type:
Group Size:
Employer Name: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip Code: 
Plan:  Benefit Amount: 
Coverage Options: 



Riders: 
Wellness Benefit Rider
Accident Only Disability Income Rider - 24 Hour Coverage
Accident Only Disability Income Rider - Off-the-Job Coverage
Benefit Period: Benefit Amount:
Payment Mode: 
   

Add New Agent Name/Address
Name: 
Address Line 1: 
Address Line 2: 
Address Line 3: 
City: 
State: 
Zip Code: 
Phone Number: 
()     - 
Confirm Delete
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Hospital Indemnity PRO+ Version 0.0.0.0 
Application State: 
California License Number: 
Type:
Group Size:
Employer Name: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip Code: 
Coverage Options: 
Benefit Amount: 
Benefit Amount
Benefit Amount 1
Benefit Amount 2
Benefit Amount 3
Benefit Amount 4
Benefit Amount 5
Benefit Amount 6
Benefit Amount 7
Benefit Amount 8
Benefit Amount 9
Benefit Amount 10
Benefit Amount 11
Benefit Amount 12
Benefit Amount 13
Benefit Amount 14
Benefit Amount 15
Benefit Amount 16
Benefit Amount
Benefit Amount 1
Benefit Amount 2
Benefit Amount 3
Benefit Amount 4
Benefit Amount 5
Benefit Amount 6
Benefit Amount 7
Benefit Amount 8
Benefit Amount 9
Benefit Amount 10
Benefit Amount 11
Benefit Amount 12
Benefit Amount 13
Benefit Amount 14
Benefit Amount 15
Benefit Amount 16
 
Benefit Period: 
Benefit/Elimination Period Combinations
Benefit Period 1 Elimination Period 1
Benefit Period 2 Elimination Period 2
Benefit Period 3 Elimination Period 3
Benefit Period 4 Elimination Period 4
 
Elimination Period: 
 
Riders: 
 Benefit Amount 
Employee: 
Spouse: 
Children: 
 Benefit Amount 
 Benefit Amount 
 Benefit Amount 
between $250 and $3000
in increments of $250
 Benefit Amount 
between $30 and $1500
in increments of $10
 Benefit Amount 
 Benefit Amount 
 Benefit Amount 
between $500 and $5,000
in increments of $100
Payment Mode: 
   
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Add New Agent Name/Address
Name: 
Address Line 1: 
Address Line 2: 
Address Line 3: 
City: 
State: 
Zip Code: 
Phone Number: 
()     - 
Confirm Delete
Are you sure you want to delete this name/address?
Cancer Expense PRO+ Version 0.0.0.0 
Cancer Expense+ and Cancer Expense PRO are only available for re-enrollments of existing groups.
Application State: 
California License Number: 
Type: Individual Worksite Group Worksite
Group Size:
Employer Name: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip Code: 
Radiation/Chemotherapy Benefit Amount: 
Benefit Amount Combinations
Radiation/Chemo Benefit Amt 1 Hospital Confinement Benefit Amt 1
Radiation/Chemo Benefit Amt 2 Hospital Confinement Benefit Amt 2
Radiation/Chemo Benefit Amt 3 Hospital Confinement Benefit Amt 3
Radiation/Chemo Benefit Amt 4 Hospital Confinement Benefit Amt 4
Radiation/Chemo Benefit Amt 5 Hospital Confinement Benefit Amt 5
Radiation/Chemo Benefit Amt 6 Hospital Confinement Benefit Amt 6
 
Hospital Confinement Benefit Amount: 
 
Coverage Options: 
Riders: 
Payment Mode: 
   
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Add New Agent Name/Address
Name: 
Address Line 1: 
Address Line 2: 
Address Line 3: 
City: 
State: 
Zip Code: 
Phone Number: 
()     - 
Confirm Delete
Are you sure you want to delete this name/address?

Whole Life PRO

 Version 0.0.0.0 
Assurity’s new Group Whole Life plan is approved in this state, but not yet available for proposal on this site. Please contact your Regional Sales Team for an employer proposal or employee rate sheet for all new groups. In this state, the old individual and group Whole Life PRO plans on this site are only available for re-enrollments of existing groups.
Application State: 
California License Number: 
Type:
Group Size:
Employer Name: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip Code: 
Employee Policy
Group Size: 
 
 
Employee Policy - Money Purchase Amounts
Money Purchase Amount 1
Money Purchase Amount 2
Money Purchase Amount 3
Money Purchase Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if deFAWLt values are not desired.
Employee Policy - Face Amounts
Face Amount 1
Face Amount 2
Face Amount 3
Face Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if deFAWLt values are not desired.
 
Riders: 
 Benefit Period 
 Benefit Amount 
 Benefit Amount 
 Permanent/Term Blend 
 Benefit Amount 
Employee Policy - Spouse Term Insurance Rider
Face Amounts
Face Amount 1
Face Amount 2
Face Amount 3
Face Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if deFAWLt values are not desired.
Group Size: 
Spouse Policy - Money Purchase Amounts
Money Purchase Amount 1
Money Purchase Amount 2
Money Purchase Amount 3
Money Purchase Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if deFAWLt values are not desired.
Spouse Policy - Face Amounts
Face Amount 1
Face Amount 2
Face Amount 3
Face Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if deFAWLt values are not desired.
 
Riders: 
 Permanent/Term Blend 
Face Amount: 
Payment Mode: 
The Product Selected is not available in this State.
 
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Add New Agent Name/Address
Name: 
Address Line 1: 
Address Line 2: 
Address Line 3: 
City: 
State: 
Zip Code: 
Phone Number: 
( )     - 
Confirm Delete
Are you sure you want to delete this name/address?
Term Life PRO Version 0.0.0.0  
Individual and group Term Life PRO are only available for re-enrollments of existing groups.
Application State: 
California License Number: 
Type:
Group Size:
Employer Name: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip Code: 
Employee Policy
Term Period:
Group Size: 
 
 
Employee Policy - Money Purchase Amounts
Money Purchase Amount 1
Money Purchase Amount 2
Money Purchase Amount 3
Money Purchase Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if default values are not desired.
Employee Policy - Face Amounts
Face Amount 1
Face Amount 2
Face Amount 3
Face Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if default values are not desired.
 
Riders: 
 Benefit Period 
 Benefit Amount 
 Benefit Amount 
 Benefit Amount 
Employee Policy - Spouse Term Insurance Rider
Face Amounts
Face Amount 1
Face Amount 2
Face Amount 3
Face Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if default values are not desired.
Term Period 
Spouse Policy - Face Amounts
Face Amount 1
Face Amount 2
Face Amount 3
Face Amount 4

Your specified amounts have changed because a dependent value was modified. Please verify the amounts if default values are not desired.
Term Period:  Face Amount: 
Payment Mode: 
The Product Selected is not available in this State.
 
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