Parsons & Associates. Inc. -- Insurance & Risk Management

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

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We only accept inquiries for insurance written in New York State

General Information
Company Name:
City:   State:   Zip:
Phone #:   Fax #:
Email Address:
Please Contact Me By:   ( Your Proposal will be delivered via this method )

Personal Information
Date of Birth (dd/mm/yyyy):     Sex:
Social Security #:
Describe Job Duties:
Annual Earnings: $   ( including all compensation: bonuses etc )
Residence State:
Tobacco User:

Current Disability Information
Do you have group disability through your employer?:
Do you currently have any type of disability insurance?:
If so, how much do you have?


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

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


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