DISABILITY INCOME QUOTE

Complete the following information if you would like to obtain a quote. Please understand this is not an application. 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.

Underwriting Information

Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, ect.? *

Yes No

Have you received disability compensation? *

Yes No

Do you smoke or chew tobacco? *

Yes No

Have you used any illegal narcotics? *

Yes No

Is your health impaired in any way? *

Yes No

Are you taking medication? *

Yes No

Do you have high blood pressure? *

Yes No

Do you have asthma, emphysema or respiratory problems? *

Yes No

Do you have cancer or other tumors? *

Yes No

Do you have diabetes? *

Yes No

Are you pregnant? *

Yes No

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

Yes No

How long do you want the benefit period to be (maximum length of time you will receive benefits after you have been classified as being disabled and satisfied the elimination period)? *

Disability Quote