Disability Quote Request

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When you’re healthy and working, it’s hard to imagine being disabled by illness or injury. But it can happen. In fact:

One in 3 working Americans will become disabled for 90 days or more before age 65. *
The average disability absence is 2 and a half years. *
More than 80% of working Americans don’t have disability income insurance or aren’t covered adequately. **

The chart below illustrates that an individual’s chances of disability are 2 to 3 times greater than death during their working years.(Source *)

* Commissioner’s Individual Disability Table A

Fields marked with * are required.

Agent Name*

Agent Phone*

Agent Email*

Client Name*

State Residence*

Birth Date*

Gender*

Tobacco Use*

Health History*

Occupation and Daily Duties*

Annual Income*

Government Employee*

Business Owner*

Current Disability Insurance Coverage*(company/amount)

Elimination Period*

Benefit Period*

Monthly Benefit*

Additional Information