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disability insurance

Disability Quote Request

Major Insurers

Quotes from reliable insurers that are highly rated and specialize in disability insurance.

Protect your income with a policy you can keep because the insurer has the competence and financial strength to be there when you need it.

Unlike life, health, and annuities, detailed information is needed to generate disability quotes.

Because of the very individual nature of disability insurance, online quoting from consumer online entry is not available.

Please complete the following so we can send customized quotes to you.

All information is confidential. You are not identified to any insurance company.

The more complete and accurate the information, the more realistic the quote can be.

Request Quotes
First Name:
Last Name:
Address – Street:
Day Phone:
Evening Phone:
Cell Phone:
E-mail address:
Repeat e-mail:
Male   Female
Benefit period preferred:
Maximum monthly premium you would consider:
Have you had a prior decline for disability insurance?  Reason, if known:
Will an employer pay the premium?  Yes  No   Monthly benefit wanted:
Tobacco use - type, amount, date of last use / never:
Medical conditions last 5 years (include mental health, HBP, cholesterol, etc.):
Physical impairments:

Medications prescribed in last year + dosage:
Been resident in a nursing home? When, reason?
History of alcohol or substance abuse/treatment:
List any risky sports/hobbies or hazardous occupations (includes private pilot):
Last 5 years, list DUI, license suspension/revocation, or other moving violations:
Foreign travel planned in the next two years:
If self-employed, average annual taxable income in the last two years:  
Whether employed or self-employed, approx. current annual earnings:  
 % of work done at home:  
C corp?
Describe occupation, specific duties, type of location, # years at occupation:
Government employee?  Yes  No   #Years:     Type:
Covered by group disability insurance?  Yes  No   Monthly benefit : $
Benefit as % of earnings  60%  67%   Employer Paid? Yes  No
Have current individual disability insurance?  Yes  No   Monthly benefit:
To remain in force? Yes  No
U.S. citizen/resident?  Yes  No   Active military duty now/soon?  Yes  No
Insurers preferred, if any; other comments:

All quotes are based on a risk category assumed on the basis of the information given.