Disability Quote Request Disability Quote Request For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.Personal InformationSelect Your StatePlease Note: We only write insurance for these states.SelectAlabamaArizonaArkansasCaliforniaColoradoConnecticut; DelawareFloridaGeorgiaIdahollinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusetts; MichiganMinnesota; MississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest Virginia WisconsinWyomingAddressWhat is your address? Street Address Address Line 2 City ZIP Code Name*What is your name? First Last What is your telephone number?*Email Address*What is your email address? FaxWhat is your fax number?What is your birth date? MM slash DD slash YYYY What is your gender? Male Female What is your height?Height (example 5' 8")What is your weight?Marital Status Married Single Divorced Widowed Underwriting InformationPilot LicenseDo you have a pilot license of any type? Yes No If Yes, What Type?Scuba Diving, Any Racing, Mountain Climbing, Hang Gliding, Skydiving, etcDo you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, etc? Yes No License Suspended or RevokedHave you had your drivers license suspended or revoked? Yes No Convicted of a FelonyHave you been convicted of a felony? Yes No Received DisabilityHave you received disability compensation? Yes No Advised to Reduce AlcoholHave you been advised by a physician to reduce your alcohol consumption? Yes No Use TobaccoDo you smoke or chew tobacco? Yes No NarcoticHave you used LSD, cocaine or any illegal narcotics? Yes No Impaired HealthIs your health impaired in any way? Yes No Taking MedicationAre you taking medication? Yes No High Blood PressureDo you have high blood pressure? Yes No Respiratory ProblemsDo you have asthma, emphysema or respiratory problems? Yes No Cancer or TumorsDo you have cancer or other tumors? Yes No DiabetesDo you have diabetes? Yes No AIDS or HIVDo you have AIDS; HIV? Yes No PregnantAre you pregnant? Yes No Declined InsuranceHave you ever been declined life, health or disability insurance? Yes No U.S. CitizenAre you a U.S. citizen? Yes No RemarksCoverage InformationWhat is 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 Self-EmployedAre you self-employed? Yes No OccupationWhat is your occupation?DutiesPlease describe briefly your duties at your current job.Reason for PurchasingIs there a particular reason why you are purchasing disability insurance? Yes No If yes, please explain.Own NowDo you have disability insurance now? Yes No If yes, how much do you have now?Questions or commentsCaptchaTo get a quote, click on the submit button belowPrint Form