Disability
Introduction to Disability Insurance | Disability Insurance Quote | Disability Links  

 

 

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DISABILITY QUOTE REQUEST
Complete the following information if you would like to obtain a quote on Disability Insurance. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your address?
Street
City
State
Zip
What is your telephone number?
Phone
What is your fax number?
Fax
What is your e-mail address?
e-mail
What is your birth date?
Birth Date
What is your gender?
Gender

Male

Female

What is your height?
Height (example 5' 8")
What is your weight?
Weight
What is your marital status?
Marital Status
Underwriting Information
All Yes answers, please explain in remarks below.
Do you have a pilot license of any type?
Pilot License

Yes

No

If Yes, What Type?
Type
Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, etc?
Scuba Diving, Any Racing, Mountain Climbing, Hang Gliding, Skydiving, etc

Yes

No

Have you had your drivers license suspended or revoked?
License Suspended or Revoked

Yes

No

Hare you been convicted of a felony?

Convicted of a Felony

Yes

No

Have you received disability compensation?
Received Disability

Yes

No

Have you been advised by a physician to reduce your alcohol consumption?
Advised to Reduce Alcohol

Yes

No

Do you smoke or chew tobacco?
Use Tobacco

Yes

No

Have you used LSD, cocaine or any illegal narcotics?
Narcotics

Yes

No

Is your health impaired in any way?
Impaired Health

Yes

No

Are you taking medication?
Taking Medication

Yes

No

Do you have high blood pressure?
High Blood Pressure

Yes

No

Do you have asthma, emphysema or respiratory problems?
Respiratory Problems

Yes

No

Do you have cancer or other tumors?
Cancer or Tumors

Yes

No

Do you have diabetes?
Diabetes

Yes

No

Do you have AIDS; HIV?
AIDS or HIV

Yes

No

Are you pregnant?
Pregnant

Yes

No

Have you ever been declined life, health or disability insurance?
Declined Insurance

Yes

No

Are you a U.S. citizen?
U.S. Citizen

Yes

No

Remarks
Coverage Information
What 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 days

60 days

90 days
6 months
1 year
2 years

How 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 years
3 years
4 years
5 years
Until age 65
Are you self-employed?
Self-Employed

Yes

No

What is your occupation?
Occupation
Please describe briefly your duties at your current job.
Duties
Is there a particular reason why you are purchasing disability insurance? Reason for Purchasing

Yes

No

If yes, please explain.
Do you have disability insurance now?
Own Now

Yes

No

If yes, how much do you have now?
Questions or comments
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
Keystone Financial Advisors

50 Main Street, Suite 1000 | White Plains, NY 10606
Phone (914) 682-2190
Fax (914) 931-8400
 
 
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