Premier Services - The Insurance Experts

Disability Income Application Form
(Quotes will be provided for Pennsylvania, New Jersey, New York, Maryland and Delaware)

Name:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Sex:

Date of Birth (MM/DD/YY):

Are you a:

Height:

Weight:

Yearly Income:

Occupation:

Job description:

Do you own your own business? Yes No

If so, how many years?

How many employees?

How much monthly benefit would you want to receive if disabled? The higher the monthly benefit, the higher the premium. (Maximum is 66% of your monthly income)

Waiting period desired? Keep in mind that the longer you can wait before you will need disability payments, which is determined by your amount of savings, the lower your premium will be:

Benefit period desired? (How many years you want to be paid disability income)

Describe any health problems:

Any cancer or heart disease within the immediate family? Yes No

If yes, please explain below:

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What was the price quoted?

Please describe the plan in detail (waiting period, number of benefit years and monthly benefit):

How did you hear about us?

Additional Comments: