Here's how simple it is to get a Disability Income quote...

Put a Professional to work for You...

Let us show you what we can do for you!  We are trained to take the mystery out of insurance, specifically addressing the replacement of income if you are disabled.  Please understand this is not an application for insurance.  An application will be sent to you if coverage is desired.

(1) Fill in your contact and other related information below.
(2) Give us some brief information about you.
(3) Re-check your information to make sure it is correct.
(4) Click the submit button (just once), sit back and relax!

Please note items with * are necessary fields.
Personal Information  
Your Salutation (Mr. Mrs. Ms. Miss): First & Last Name:
 *
Address (1)
 *		 Address (2)
City:
 *		 State:
 *		 Zip
 *
Your e-mail:
 *		 please check your complete e-mail again
(AOL users please use complete address)
Daytime phone:
*  please check it twice		 Evening phone:
 *  please check it twice
  Gender Height and Weight Birthdate
  Male   Female * (example 5'8")
* lbs.		 *
    (mm/dd/yy)
What is your marital status?
 
Underwriting Information
For all "Yes" answers, please provide a brief explanation
Do you have a pilot license of any type? YesNo   if yes, what type:
Do you participate in scuba diving, any racing, mountain climbing, hang gliding, sky-diving, etc? YesNo  if yes, explain:
Have you had your drivers license suspended or revoked? YesNo  if yes, explain:
Have you been convicted of a felony? YesNo  if yes, explain:
Have you received disability compensation? YesNo  if yes, explain:
Have you been advised by a physician to reduce your
alcohol consumption?		 YesNo  if yes, explain:
Do you smoke or
chew tobacco?		 YesNo  if yes, select:
Have you used LSD, cocaine
or any illegal narcotics?		 YesNo  if yes, explain:
Is your health impaired
in any way?		 YesNo  if yes, explain:
Are you taking medication? YesNo  if yes, explain:
Do you have high blood pressure? YesNo  if yes, explain:
Do you have asthma, emphysema or respiratory problems? YesNo  if yes, explain:
Do you have cancer or
other tumors?		 YesNo  if yes, explain:
Do you have diabetes? YesNo  if yes, explain:
Do you have AIDS; HIV? YesNo  if yes, explain:
Are you pregnant? YesNo  if yes, explain:
Have you ever been declined
life, health or disability insurance?		 YesNo  if yes, explain:
Are you a U.S. citizen? YesNo  
Coverage Information
What is your annual gross salary, including tips, fees, and commissions?  $ 
How long have you been employed at your present occupation?     
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 (the length of time you must be disabled before you start to receive benefits)?
30 days
60 days
90 days		 6 months
1 year
2 years
   
How long do you want the benefit period to be
(the maximum length of time you will receive benefits after you have been classified as being disabled and satisfied the elimination period)?
1 year
2 years
3 years		 4 years
5 years
Until age 65
Are you self-employed? YesNo
What is your occupation?     
Please describe briefly your duties
at your current job.		     
Is there a particular reason why you are purchasing disability insurance?
YesNo  Please explain:
Do you have disability insurance now? YesNo
Best Time to Contact You
Please let us know the best time to call and discuss your health quote.  * Morning  Afternoon  Evening  Anytime
Other Comments?

(* indicates necessary fields)

 

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