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Complete the following information if you would like to obtain a quote on Disability Insurance. Please understand this is not an application for insurance. 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.
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Personal Information |
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What is your name? |
Last
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First
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Middle
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What is your address? |
Street
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City
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State
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Zip
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What is your telephone number? |
Phone
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What is your fax number? |
Fax
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What is your e-mail address? |
e-mail
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What is your birth date? |
Birth Date
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What is your gender? |
Gender
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Male
Female
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What is your height? |
Height (example 5' 8")
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What is your weight? |
Weight
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What is your marital status? |
Marital Status
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Underwriting Information |
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All Yes answers, please explain in remarks below. |
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Do you have a pilot license of any type? |
Pilot License
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Yes
No
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If Yes, What Type? |
Type
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Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, etc? |
Scuba Diving, Any Racing, Mountain Climbing, Hang Gliding, Skydiving, etc
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Yes
No
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Have you had your drivers license suspended or revoked? |
License Suspended or Revoked
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Yes
No
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Hare you been convicted of a felony?
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Convicted of a Felony
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Yes
No
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Have you received disability compensation? |
Received Disability
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Yes
No
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Have you been advised by a physician to reduce your alcohol consumption? |
Advised to Reduce Alcohol
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Yes
No
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Do you smoke or chew tobacco? |
Use Tobacco
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Yes
No
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Have you used LSD, cocaine or any illegal narcotics? |
Narcotics
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Yes
No
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Is your health impaired in any way? |
Impaired Health
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Yes
No
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Are you taking medication? |
Taking Medication
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Yes
No
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Do you have high blood pressure? |
High Blood Pressure
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Yes
No
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Do you have asthma, emphysema or respiratory problems?
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Respiratory Problems
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Yes
No
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Do you have cancer or other tumors? |
Cancer or Tumors
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Yes
No
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Do you have diabetes? |
Diabetes
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Yes
No
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Do you have AIDS; HIV? |
AIDS or HIV
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Yes
No
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Are you pregnant? |
Pregnant
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Yes
No
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Have you ever been declined life, health or disability insurance? |
Declined Insurance
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Yes
No
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Are you a U.S. citizen? |
U.S. Citizen
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Yes
No
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Remarks |
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Coverage Information |
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What is your annual gross salary, including tips, fees, and commissions? |
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How long have you been employed at your present occupation?
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What percentage of your income do you want your disability policy to cover? |
50%
60%
65%
70%
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How long do you want the elimination period to be (the length of time you must be disabled before you start to receive benefits)?
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30 days
60 days
90 days
6 months
1 year
2 years
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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)? |
2 years
3 years
4 years
5 years
Until age 65
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Are you self-employed? |
Self-Employed
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Yes
No
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What is your occupation? |
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Please describe briefly your duties at your current job. |
Duties
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Is there a particular reason why you are purchasing disability insurance? |
Reason for Purchasing |
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If yes, please explain. |
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Do you have disability insurance now?
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Own Now
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Yes
No
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If yes, how much do you have now? |
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Questions or comments |
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Best Time to Contact You
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Please let us know the best time to call and discuss your quote.
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Morning
Afternoon
Evening
Anytime
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Or specify other:
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