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Disability
Quote

Filter Type:
Personal Information
Name:
Email:
Home Phone:
Fax:
Address:
City:
State:
Zip:
Birthdate:
Height:
Weight:
 Male Female
 Married Single
Underwriting Information
All Yes answers, please explain in remarks below.
Do you have a pilot license of any type?
 No Yes
If Yes, What Type?
Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, etc?
 No Yes
Have you had your drivers license suspended or revoked?
 No Yes
Have you been convicted of a felony?
 No Yes
Have you received disability compensation?
 No Yes
Have you been advised by a physician to reduce your alcohol consumption?
 No Yes
Do you smoke or chew tobacco?
 No Yes
Have you used LSD, cocaine or any illegal narcotics?
 No Yes
Is your health impaired in any way?
 No Yes
Are you taking medication?
 No Yes
Do you have high blood pressure?
 No Yes
Do you have asthma, emphysema or respiratory problems?
 No Yes
Do you have cancer or other tumors?
 No Yes
Do you have diabetes?
 No Yes
Do you have AIDS; HIV?
 No Yes
Are you pregnant?
 No Yes
Have you ever been declined life, health or disability insurance?
 No Yes
Are you a U.S. citizen?
 No Yes
Remarks
Coverage Information
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)?
 2 years 3 years 4 years 5 years Until age 65
Are you self-employed?
 No Yes
What is your occupation?
Please describe briefly your duties at your current job.
Is there a particular reason why you are purchasing disability insurance?
 No Yes
If yes, please explain.
Do you have disability insurance?
 No Yes
If yes, how much do you have?
Questions or comments
When is the best time to call and discuss your quote?
 Morning Afternoon Evening Anytime Other
If other, please specify:
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