Disability Insurance Quote

The quote you have requested requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.

 

Contact Information
*First Name
Last Name
*Email Address
Work Phone
Home Phone
City
State	Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Quote Information
Date of Birth	(mm/dd/yy)
Gender	Male Female
Tobacco user?	No Yes
Height	(ex: 5'8")
Weight	(ex: 150 lbs)
Occupation
Exact Duties
Business Owner?	No Yes
How many full-time employees?
Number of years owned
Current Annual Income: (include all compensation: bonuses, dividends etc - documentation will be required )
Is there disability coverage currently in force?	No Yes
If yes, How much?
Current Carrier
Most Important?	Cost Benefit
Desired Annual Benefit
Desired Benefit Period	2 years 5 years 10 years until age 65
Desired Waiting/Elimination Period:	option value="30 days">30 days 60 days 90 days 180 days 365 days
Employer Paid?	No Yes
Please describe any and all health conditions you have (or have had) in the past and/or any medications you are currently taking:
Additional Considerations/ Requests
Please give any additional comments you feel appropriate for this quotation.
Please click on the "Submit Request" button to send us your quote request. An Agent will contact you shortly.

 

 

 

 

Legacy Planning Group. Copyright © 2007

This information is designed to provide a general overview with regard to the subject matter covered and is not state specific.
The authors, publisher and host are not providing legal, accounting or specific advice to your situtation.