Disability Insurance

Thank you for your interest.

Disability insurance helps replace income lost because of an accident or illness. One survey found that 43% of people aged 40 will suffer a disability of at least 90 days before they reach age 65.1

After completing the form, please click on the “Submit” button. Your information will be emailed to our offices and we will process your request. All information will be kept confidential.

1. 2000 Field Guide, National Underwriter

Please use the form below to contact us.







Contact Information

 
Name
Email
Phone
Address1
City
State
Zip

Personal Information

 
M/F

Male
Female
Height

Weight

Tell Us About Your Work

 
What is your occupation?

Describe your daily duties:

Do you own a business?

Yes
No
Estimate your current monthly income:

Is disability insurance part of your benefit package?

Yes
No

Policy Information

 
How much of your income do you want disability insurance to replace?

20%
30%
60%
70%
If you become disabled, what’s your desired waiting period before benefits begin?

30 days
60 days
90 days
180 days
If you become disabled, how long do you want to be eligible for benefits?

2 years
5 years
10 years
until 65

Additional Considerations

 
Are you a tobacco user? Are you a

Yes
No
How would you describe your health?

Excellent
Very Good
Good
Poor
Any additional information to consider as we process your request?