Disability Insurance Quote Request
This is a solicitation for disability insurance and related sickness and accident coverages. An insurance agent will contact you by email and phone with your custom proposal.
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First Name *
Last Name *
Email *
Phone number *
Street Address *
City *
State *
Zip Code *
Date of Birth *
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Gender - This is required because premiums are sex-distinct on most products, in almost all jurisdictions. *
Do you use any form of tobacco? This is required because premiums vary based on tobacco usage. *
Your Occupation. This is important because premiums are occupation-specific. If you have more than one occupation, please include them all. *
What kind of coverage are you interested in? You may check more than one box. *
Required
Build. What is your height and weight?
Are you a business owner?
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Are you a student or a new professional? New Professional is someone that is within their first two years of practice in one of the following areas: Accounting, Architect, Certified Registered Nurse Anesthetist, Dental, Engineer, Information Technology, Legal, Medicine, Nurse Practitioner, Optometry, Pharmacist, Ph.D. Psychologist, Physician's Assistant, Podiatrist/Chiropodist, Veterinarian.
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Are you a government employee?
Income and Inforce Coverage. This information is necessary to provide you with a customized proposal that reflects eligibility based on your current earned income and existing disability coverage.
Annual Earned Income (base salary or base wage). This is required for a custom proposal. *
Annual Bonus (includes commissions and other incentive pay)
Inforce Individual Disability Coverage. This is insurance that you pay for with your own money. What we need to know is the monthly benefits, the waiting periods, and benefit periods. If you are not sure, please write what you know, or "unsure" and your agent will discuss with you. If you do not have any personal disabilty insurance inforce, please write "none."
Group Long Term Disability Percent. This is insurance your employer pays for, usually stated as a percentage of your annual income (i.e., 66%). If you don't have any Group LTD at work, please type "none."
Group Long Term Disability Cap. This is the maximum monthly benefit your employer-provided group coverage will pay. The most common cap is $5,000 per month, but some pay more or less. Ask your Human Resources department or consult your benefit summary they provide every year. If this does not apply to you, then you may leave this blank.
Does your Group Long Term Disability cover any bonuses, or just your base salary?
Benefits and Riders. This section asks questions regarding how much coverage you need, when your monthly benefits are paid, and how long benefits are paid, as well as any optional policy riders that provide more comprehensive coverage.
Benefit Period.  When you get sick or hurt and cannot work, how long do you want benefits to be paid to you while you are disabled? *
Waiting Period. This is how long you need to be unable to earn an income due to sickness or injury before benefits begin to accrue. *
Benefit Amount. This is the monthly benefit that you will be paid while you are disabled. If you are not sure how much benefit to request, you can select Max and we will figure it out for you.
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Premium Mode. This is how often you pay your premiums. Annual is the lowest total cost, followed by Semi-Annual. The quarterly premium mode has the highest total cost. Monthly Bank Draft (EFT) is less than Quarterly and the most popular billing mode. *
Residual Disability Rider. To receive disability benefits for residual disability, you must have either a loss of duties — which means you are able to perform some but not all substantial and material duties — or a loss of time — which means you are able to perform all substantial and material duties but you are unable to do them at least 20% of the time — and you must have a loss of income of at least 20% of your prior monthly earnings. These riders are optional. Ask your agent for a detailed Outline of Coverage and a brochure for more information. *
Non-Cancelable. If you want a guarantee that your premium rates cannot be changed by the insurance company, the optional Non-cancelable Policy Rider will allow you to do so. *
Own Occupation Rider. With this optional rider, you will be considered totally disabled if, due to injury or sickness, you are unable to perform the substantial and material duties of your regular occupation, even though you may be working in another gainful occupation. Physicians and dentists working in an ABMS, AOABOS or ADA recognized specialty will have that specialty deemed their regular occupation. Attorneys performing the usual and customary duties of a trial attorney will have trial attorney deemed their regular occupation. *
Cost of Living. Just as inflation affects the value of your savings, the value of your disability income coverage can be eroded by inflation. With a Cost of Living Rider, while you are disabled the monthly benefit payment can increase annually. Increases will be based on changes in the Consumer Price Index.
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Catastrophic Disability Benefit. In the event you suffer a catastrophic disability, you may need additional help to offset your expenses. The Catastrophic Disability Benefit Rider pays you a monthly benefit in addition to the disability benefits paid for total disability. Catastrophic disability means you are unable to perform two or more activities of daily living without assistance, you have a severe cognitive impairment, or you have a Presumptive Total Disability. Activities of daily living include: bathing, continence, dressing, eating, toileting and transferring. Transferring means moving into or out of a bed, chair or wheelchair, with or without adaptive devices. If you do not know how much you can purchase, select Max and we will calculate it for you. *
Discounts. You may be eligible for a discounted premium. Check each box that applies to you.
If you are an insurance agent asking for a quote for a client, please enter your name below. Thank you.
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