Disability Insurance Quote Request

For the most accurate quote possible, please complete all fields. We keep all data strictly confidential - please see our Privacy Policy. If you have serious health problems or unusual circumstances, or if you are interested in a quote for business overhead expense coverage or retirement plan protection, please call (toll free) 877-962-8737 for a no-cost, confidential consultation.*Red = Required Field

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This form is for Physicians.
Click here if you are a not a physician »

Your Name:*
Sex:*	M F
DOB:*
Height:*	Weight:*
Tobacco Use:*	Never Cigarettes - Number per day: Cigars - Number per day: Other, please list details: Date of last use:
Phone (work):
Phone (home):
Phone (cell):
E-mail:
Address:
City:
State:*	Zip:

occupation details
Medical Practice Specialty:*
What percent of your work is performing invasive procedures or surgery?:*	%
Years:* (need two years history)
Employment Status:*	Employee with a physician group, hospital, etc. Federal government employee State/Local government employee Sole practitioner Partner in a group % ownership Independent contractor (Locum Tenens) Resident Physician/Fellow Year: Program name: Student Other:
Annual Base Income:*	$
Annual Bonus Income:*	$
Unearned Income:	$

Disability Policy Benefits Desired
Monthly Benefit Desired:*	$ or maximum available
Elimination Period:*	90 180 365
Replacement:*	yes no
Total Current Individual Disability Benefit (if any):*	$
Existing Group Coverage	Monthly % Monthly Maximum $ Paid by Employer Paid by Employee

Lifestyle Details
U.S. Citizen:	yes no If no, place of birth: Status:
Travel:	Do you plan foreign travel in the next two years? yes no If yes, list details:
Activities:	Do you engage in hazardous sports such as: Private Piloting Scuba Diving Rock Climbing Auto Racing Sky Diving Other? Please explain:

delivery options
Deliver quote by:* (choose preferred method)	e-mail: phone: fax:
Date quote needed:*
	*Red = Required Field

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Health Details
Have you been treated for or diagnosed with any of the following: (check all that apply)	Diabetes Cancer or Tumor Heart Attack or Disease Stroke/Neurological Disorder Asthma or Lung Disease Elevated Blood Pressure Kidney Disorder Elevated Cholesterol Drug or Alcohol Abuse Back or Spine Disorder Sleep Apnea Date of Test: Blood Disorders Elevated Liver Functions or Liver Disorder
Any history of anxiety, depression, psychological counseling?	yes no If yes, please provide details below, including dates of diagnosis and treatment:
Medications in the past 5 years?	yes no If yes, please provide details below, including dates, details and reason:
Hospitalizations or Surgeries in past 10 years?	yes no If yes, please provide details below, including dates of diagnosis and treatment:
Treatment by a chiropractor?	yes no If yes, please provide details below, including dates of diagnosis and treatment:
Has a parent or sibling been diagnosed with or died from heart disease or cancer before age 60?*	yes no If yes, please provide details below, including dates of diagnosis and treatment: