Disability Insurance Quote

DISABILITY QUOTE REQUEST
Complete the following information if you would like to obtain a quote on Disability Insurance. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?	Last
	First
	Middle
What is your address?	Street
	City
	State
	Zip
What is your telephone number?	Phone
What is your fax number?	Fax
What is your e-mail address?	e-mail
What is your birth date?	Birth Date
What is your gender?	Gender	Male Female
What is your height?	Height (example 5' 8")
What is your weight?	Weight
What is your marital status?	Marital Status
Underwriting Information
All Yes answers, please explain in remarks below.
Do you have a pilot license of any type?	Pilot License	Yes No
If Yes, What Type?	Type
Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, etc?	Scuba Diving, Any Racing, Mountain Climbing, Hang Gliding, Skydiving, etc	Yes No
Have you had your drivers license suspended or revoked?	License Suspended or Revoked	Yes No
Hare you been convicted of a felony?	Convicted of a Felony	Yes No
Have you received disability compensation?	Received Disability	Yes No
Have you been advised by a physician to reduce your alcohol consumption?	Advised to Reduce Alcohol	Yes No
Do you smoke or chew tobacco?	Use Tobacco	Yes No
Have you used LSD, cocaine or any illegal narcotics?	Narcotics	Yes No
Is your health impaired in any way?	Impaired Health	Yes No
Are you taking medication?	Taking Medication	Yes No
Do you have high blood pressure?	High Blood Pressure	Yes No
Do you have asthma, emphysema or respiratory problems?	Respiratory Problems	Yes No
Do you have cancer or other tumors?	Cancer or Tumors	Yes No
Do you have diabetes?	Diabetes	Yes No
Do you have AIDS; HIV?	AIDS or HIV	Yes No
Are you pregnant?	Pregnant	Yes No
Have you ever been declined life, health or disability insurance?	Declined Insurance	Yes No
Are you a U.S. citizen?	U.S. Citizen	Yes No
Remarks
Coverage Information
What 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
Are you self-employed?	Self-Employed	Yes No
What is your occupation?	Occupation
Please describe briefly your duties at your current job.	Duties
Is there a particular reason why you are purchasing disability insurance?	Reason for Purchasing	Yes No
If yes, please explain.
Do you have disability insurance now?	Own Now	Yes No
If yes, how much do you have now?
Questions or comments
Best Time to Contact You
Please let us know the best time to call and discuss your quote.	Morning Afternoon Evening Anytime	Or specify other: