Low Load Insurance Services Photo Banner

Quote Request » Disability

For the most accurate quote possible, please complete all fields. We keep all data strictly confidential - please see our Privacy Policy. Use your Tab key to go forward and Shift+Tab to go back. Please do not hit "Enter" or click "Submit" until the form has been completed. If your client has serious health problems or unusual circumstances, please call (toll free) 877-254-4429 for a no-cost, confidential consultation. *Red = Required Field

 view printer-friendly form

 

Advisor:*
Proposed Insured Name:*
Sex:* M     F
DOB:*
Height:*    Weight:*
Tobacco Use:* yes    no
If yes, please list details:
Phone (work):
Phone (home):
Phone (cell):
Fax:
E-mail:
Address:
City:
State:*    Zip:
   
occupation details
Occupation:*
Employer:*
Years:*
(need two years history)
Government Employee:* yes    no
Workplace:* home    office
W-2 Employee:* yes    no
Business Owner:* yes    no
If yes, indicate type of business:
S-Corp   C-Corp   Partnership  
Sole Proprietor  LLC
Owner Percentage:
Annual Base Income:* $
Annual Bonus Income:* $
Unearned Income: $
   
Disability Policy Benefits Desired
Monthly Benefit Desired:* $ or maxium available
Elimination Period:* 90   180   365
Replacement:* yes    no
Total Current Individual Disability Benefit (if any):* $
Existing Group Coverage Monthly %
Monthly Maximum $
Paid by Employer
Paid by Employee
   
Health Details
Have you been treated for or diagnosed with any of the following: (check all that apply) Diabetes
Cancer or Tumor
Heart Attack or Disease
Stroke/Neurological Disorder
Asthma or Lung Disease
Elevated Blood Pressure
Kidney Disorder
Elevated Cholesterol
Drug or Alcohol Abuse
Back or Spine Disorder
Blood Disorders
Elevated Liver Functions
Any history of anxiety, depression, psychological counseling? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Medications in the past 5 years? yes    no
If yes, please provide details below, including dates, details and reason:
Hospitalizations or Surgeries in past 10 years? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Treatment by a chiropractor? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Has a parent or sibling been diagnosed with or died from heart disease or cancer before age 60?* yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Lifestyle Details
U.S. Citizen: yes    no
If no, place of birth:
Status:
Travel: Do you plan foreign travel in the next two years?
yes    no
If yes, list details:
Activities: Do you engage in hazardous sports such as:
Private Piloting
Scuba Diving
Rock Climbing
Auto Racing
Sky Diving
Other? Please explain:
   
delivery options
Deliver quote by:*
(choose preferred method)

e-mail:

phone:

fax:

Date quote needed:*
  *Red = Required Field