Disability Insurance Quote

Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information
*First Name
*Last Name
Street Address
City/St/Zip
*Phone Number
Alternate Number
*Email Address
Birthdate
Gender  Male Female
Height (example 5'8")
Weight (lbs)
Marital Status

Underwriting Information

Do you have a pilot license of any type?  Yes No
  If yes, what type?
Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, ect.?  Yes No
Have you had your drivers license suspended or revoked?  Yes No
Have you been convicted of a felony?  Yes No
Have you received disability compensation?  Yes No
Have you been advised by a physician to reduce your alcohol consumption?  Yes No
Do you smoke or chew tobacco?  Yes No
Have you used any illegal narcotics?  Yes No
Is your health impaired in any way?  Yes No
Are you taking medication?  Yes No
Do you have high blood pressure?  Yes No
Do you have asthma, emphysema or respiratory problems?  Yes No
Do you have cancer or other tumors?  Yes No
Do you have diabetes?  Yes No
Do you have AIDS, HIV?  Yes No
Are you pregnant?  Yes No
Have you ever been declined life, health or disability insurance?  Yes No
Are you a U.S. citizen?  Yes No
Remarks:

Coverage Information

Annual Gross salary including tips, fees, and commissions
What percentage of your income do you want your disability policy to cover?  50% 60% 65% 70%
How long do you want the elimination period to be (length of time you must be disabled before you start to receive benefits)?
How long do you want the benefit period to be (maximum length of time you will receive benefits after you have been classified as being disabled and satisfied the elimination period)?
Are you self-employed?  Yes No
What is your occupation?
Please describe your duties at your current job:
Please explain your reason for purchasing disability insurance:
Do you currently have disability insurance?  Yes No
  If yes, how much?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote  Morning Afternoon Evening Anytime Or Specify Other:
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