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.SelectCaliforniaAddressWhat 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? Date Format: MM slash DD slash YYYY What is your gender?MaleFemaleWhat is your height?Height (example 5' 8")What is your weight?Marital StatusMarriedSingleDivorcedWidowedUnderwriting InformationPilot LicenseDo you have a pilot license of any type?YesNoIf 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?YesNoLicense Suspended or RevokedHave you had your drivers license suspended or revoked?YesNoConvicted of a FelonyHave you been convicted of a felony?YesNoReceived DisabilityHave you received disability compensation?YesNoAdvised to Reduce AlcoholHave you been advised by a physician to reduce your alcohol consumption?YesNoUse TobaccoDo you smoke or chew tobacco?YesNoNarcoticHave you used LSD, cocaine or any illegal narcotics?YesNoImpaired HealthIs your health impaired in any way?YesNoTaking MedicationAre you taking medication?YesNoHigh Blood PressureDo you have high blood pressure?YesNoRespiratory ProblemsDo you have asthma, emphysema or respiratory problems?YesNoCancer or TumorsDo you have cancer or other tumors?YesNoDiabetesDo you have diabetes?YesNoAIDS or HIVDo you have AIDS; HIV?YesNoPregnantAre you pregnant?YesNoDeclined InsuranceHave you ever been declined life, health or disability insurance?YesNoU.S. CitizenAre you a U.S. citizen?YesNoRemarksCoverage 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 days60 days90 days6 months1 year2 yearsHow 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 years3 years4 years5 yearsUntil age 65Self-EmployedAre you self-employed?YesNoOccupationWhat 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?YesNoIf yes, please explain.Own NowDo you have disability insurance now?YesNoIf yes, how much do you have now?Questions or commentsCaptchaTo get a quote, click on the submit button belowPrint Form