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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.

Thank You For Filling Out This Form COMPLETELY!

First Name:
Last Name:
E-mail Address:
State of Residence:
Telephone Number:
Date of Birth:
Tobacco Use:
Health History:
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
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:
Would You Like A Term Life Insurance Quote?:
If Yes, For What Amount?:
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About Us
Contact Us
Financial Solutions Group, Inc.

1311 S. Main St., Suite 208
Mt. Airy, MD 21771

Phone: 410-960-7634
Email Us

Hours of Operation:

Mon-Fri: 9:00am-5:00pm EST
Saturday - By appointment
Sunday - Closed

Finding the right disability and life insurance at the right price has never been easier!


**Page information taken from various sources including, but not limited to "From Here To SecuritySM", The National Underwriter Company, National Safety Council, The Society of Actuaries, Social Security Forum, New York Post, Association of Health Insurance Advisors, Health Insurance Association of America, With Permission © Insurance Information Institute, Inc. - ALL RIGHTS RESERVED - or otherwise noted** 

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