Request Your Disability Income Insurance Quote

Disability Insurance Quote Request Form

To obtain your copy of "From Here To Security", A Step-By-Step Guide To Disability Insurance and your personally prepared disability insurance quote, please complete the following questionnaire and click "SUBMIT" below. Be sure to complete the entire questionnaire in detail as this will aid us in providing you with the most accurate quote. All information provided by you is confidential and will be used solely for the purpose of providing you with a quote for insurance. We will never sell, share or rent your information to any third parties for any reason. Disability Insurance Terminology - Use when completing the form below. Waiting Period/Elimination Period - The waiting period/elimination period is the length of time you must be disabled before disability income benefits begin to be paid. During this period of disability, no benefits are payable. The waiting/elimination period can be as short as 14 days or as long as a year. As a rule, the shorter the waiting period, the more expensive a policy will be. Most people choose either a 90-day or 180-day waiting period. Consider your available savings and assets when making this choice. Benefit Period - The benefit period is the length of time disability income benefits are paid. The shortest benefit period is usually one or two years. A five-year benefit period is a fairly common feature of a disability insurance policy. Most people purchase coverage that lasts until age 65, or longer if available. You should buy the longest benefit period you can afford. Monthly Benefit - The "monthly benefit" is the dollar amount paid monthly for a qualifying disability. When you buy a private disability income insurance policy, you can expect to replace from 50% to 70% of your income. Insurance companies won't replace all your income because they want you to have an incentive to return to work. However, when you pay the premiums yourself, disability benefits are not taxed (Benefits from employer-paid policies are subject to income tax). The amount of monthly benefit you apply for directly relates to your premium. Generally, the higher the benefit, the higher the premium.
First Name:
Last Name:
E-mail Address:
State of Residence:
Telephone Number:
Gender:
Date of Birth:
Tobacco Use:
Health History:	Include any treatments, therapies, current medications, past or upcoming surgeries.
Occupation and Daily Duties:
Annual Income (business owners - net income after expenses):
Government Employee:
If Yes, For How Long?:
Business Owner:
If Yes, For How Long?:
Current Disability Insurance Coverage (company/amounts):	Provide details to any disability coverage that you may have personally or through work.
Desired Waiting /Elimination Period:
Desired Benefit Period:
Desired Monthly Benefit (type "max" for the maximum monthly benefit available):
Why Do You Want Disability Insurance At This Time?:
Additional Information:	Use this section for any specific requests or additional information you would like us to consider.
Would You Like A Term Life Insurance Quote?:
If Yes, For What Amount?:	$

Thank You For Filling Out This Form COMPLETELY!

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