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DISABILITY INSURANCE QUOTE - Individual

We would like to provide you with a free, no-obligation disability insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

    
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Personal Information
Insured's Name (First, Last): Date of Birth:
Sex: Tobacco Use:   US Citizen / Green Card:  
Male   Female Yes   No Yes   No
Physical Address:
City:   State:   Zip:
Is the mailing address the same as the physical address? Y N
Mailing Address:
City:   State:   Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:

How Did You Hear About Us?
Please check all that apply:
Search Engine Social Network Advertisement Family or Friend
Forum/Blog Co-Worker Other:

Employment Information
Employer: City/State: Occupation:
How Long Worked Here: Full Time (min 30 hrs wk): Actively working past 90 days:
Yes   No Yes   No
Job Duties: (Include title, duties, % of time in sales/travel/supervision etc. List any degrees and professional designations):
Base Salary (Net monthly): Commissions (Net monthly): Bonus/Other Incentive Compensation:
$ $ $
Monthly Retirement
Contributions:
Employer Match: Participant in Social Security/
recent statement:
$ % Yes   No
Annual Salary: 2 Years Ago: Annual Salary: 1 Year Ago: Annual Salary: This Year (Estimated):
$ $ $

Other Information
Other Earned Household Income (Monthly):
Source: Amount: $
Source: Amount: $
Unearned Income (Monthly):
Source: Amount: $
Source: Amount: $
Other Personal Information:
Any Recent Hospitalizations or Surgeries? (explain if Yes)
List Current Medications:
Existing disorders related to:
Musculoskeletal   Cardiovascular/Circulatory   Central Nervous System   Mental/ Psychiatric

Sources of Disability Income Insurance
Group Short Term Disability (GSTD)
Percentage of Salary: Maximum Benefit: Benefit Period (years): Waiting Period (days):
% $
Does GSTD include Bonus/other Incentive Compensation? Who is Premium Paid by:
Yes   No Company   Self
Group Long Term Disability (GLTD)
Percentage of Salary: Maximum Benefit: Benefit Period (years): Waiting Period (days):
% $
Does GLTD include Bonus/other Incentive Compensation? Who is Premium Paid by:
Yes   No Company   Self
Employer's policy regarding continued employment in the event
of a long term disability, if other than separation of services?

Other Individually Owned Disability Income Insurance Policy(ies)
  Policy #:   Carrier:
  Policy #:   Carrier:
  Policy #:   Carrier:

Assets / Expenses
  Assets:     Expenses:
Savings Value
(bank accounts, CDs, etc):
$ Mortgage/Rent: $
Investments Value
(stocks, mutual funds):
$ Home Owners Insurance: $
401K Value: $ Auto/Transportation: $
IRAs Value: $ Auto Insurance: $
Pension/Defined Benefit Value: $ Taxes: $
Other Tax Deferred
Instruments Value:
$ Life Insurance Premiums: $
Insurance Policies Cash Value: $ Disability Income Ins. Premiums: $
Total Savings/Retirement Assets: $ Health Insurance Premiums: $
Food: $
Primary Residence (Net Value): $ Utilities: $
Other Real Estate (Net Value): $ Education: $
Total Net Value Real Estate: $ Child Care/Elder Care: $
Credit Cards: $
Art/Jewelry (Appraised Value): $ Other Loan Payments: $
Other Assets: $ Other Monthly Expenses: $
Total Value Other Assets: $  
 
Total Assets (all sources): $ Total Monthly Expenses: $

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional
information where there was not enough fields above, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   


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