Disability Quote
General Information
Name
*
Address
City
State
Choose State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
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Delaware
Florida
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Hawaii
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Phone
Fax
Email
*
How did you hear about us?
Quote Information
Gender
Male
Female
Date of birth
Height
Weight
Have you used any tobacco products in the past 5 years?
Yes
No
If used at all in the past, how many years since last used?
Are you currently taking prescription medications?
No
Yes
If yes, list type and condition taken for:
Do you have any hazardous hobbies?
No
Yes
If yes, briefly describe:
Your occupation:
Briefly describe your exact job functions
Do you work less than 30 hours per week?
Yes
No
Are you self employed or own greater than 25% of a business?
No
Yes
If yes...
How many years?
How many full time employees?
Type of business entity:
Sole proprietor
C-corp
S-corp
Partnership
Other Covered by SDI (state disability insurance)?
Yes
No
Are you an employee of a school, federal, state, county, municipality, or other government or public entity?
No
Yes
If yes, how many years of service:
What percentage of your occupational duties are perfomed at home (0-100%)?
%
Earned income (after business expenses) reported on last tax filing?
$
Premium to be paid by
Yourself
Employer
Do you have a disability insurance policy in place now?
No
Yes
If yes...
What is your monthly or maximum benefit?
Is it:
Individual plan
Group plan
Will you keep that coverage in force?
Yes
No
Any special health or other underwriting considerations?
