Please read this information before filling out our form.
We ask more questions than other quote request forms to improve efficiency and accuracy for our clients. . We work with hundreds of doctors around the country and we understand that your time is valuable so we try to make this process easy and informative. We are looking to work with people who are serious about buying income protection, we are not looking to be a quote engine for people who are not truly interested in this protection for themselves. We will not sell your information to any other businesses and we will not put you on any email lists. We also promise not to bombard any clients with unnecessary emails. We will only contact you regarding this disability insurance request unless you indicate interest in our other services i.e. tax prepartation, student loan strategies, financial planning. Please feel confident that filling this form out will not subject you to unwanted solicitations and years of "following" up with annoying phone calls, text messages, paper mail, or emails.
We will shop the top carriers and provide you with an unbiased analysis of the different policies that are available to suit your needs. Please understand that as an independent disability insurance agent we will have about the same pricing as other agents with few exceptions. There are 5 top companies that provide disability insurance and all independent agents get the same pricing with the companies.
If you are currently working with or have already received quotes from another agent(s) then our firm will not be able to provide anything different than what you have probably seen. If you have already seen quotes from MassMutual, Guardian, Principal, Standard and Ameritas then please don't fill out this form unless you are not happy with your current agent or if there is a specific quote that you have not seen yet. If you are not happy with your current agent then we will still be happy to assist you with your purchase.

Medical Occupation Information

Personal Information Needed To Create Quotes

Which quotes have you seen already? *
About the applicant *
Income history
 2018 Current YTD20172016
What was your income in...
General Risk Questions *
---Medical Questions--- Have you EVER been diagnosed or treated by a licensed member of the medical profession for: *
a. Any disease or impairment of the heart; arteries or veins; chest pains; high blood pressure (Hypertension) or low blood pressure (Hypotension)?
b. Arthritis; any disease, disorder or deformity of the bones, muscles, tendons, or joints, including the spine; any neck or back problems or impairments; carpal tunnel syndrome; any autoimmune diseases such as lupus or scleroderma, myofascial pain syndrome, complex regional pain syndrome or reflex sympathetic dystrophy syndrome?
c. Any mental, nervous or emotional problem, condition or impairment, including anxiety, depression, insomnia, stress or post traumatic stress disorder?
d. Stroke, embolism, or thrombosis?
e. Cancer, tumor or polyp?
f. Diabetes, high blood sugar or low blood sugar (hypoglycemia)?
g. Any disease or impairment of the lungs or respiratory system, asthma, allergy, emphysema, chronic obstructive pulmonary disease or sleep apnea?
h. Any disease or disorder of the liver, gall bladder, pancreas, digestive tract, including intestines; ulcerative colitis, Crohn’s disease or hernia?
i. Memory loss, loss of concentration, fatigue, neurological impairment, unconsciousness, loss of cognition, dizziness, paralysis or numbness, impairment of nervous system, epilepsy, seizures, migraine headaches, restless leg syndrome, polio, post polio syndrome or multiple sclerosis?
j. Any disease or impairment of the urinary tract or kidney; sugar, albumin or blood in urine?
k. Any physical deformity or physical impairment?
l. Any disease or impairment of the skin?
m. Any disease or impairment of glands; anemia, leukemia, bleeding or clotting impairment or other blood impairment?
n. Any disease or impairment of the prostate or testes; uterus, ovaries or breasts; pre-term labor or infertility?
o. Any disease or disorder or impairment of the eyes, ears, mouth, nose or throat; any decrease of vision or hearing?
p. Endocrine impairment or goiter or disease or impairment of the thyroid gland?
q. Any sexually transmitted disease?
r. Attention deficit disorder, attention deficit hyperactivity disorder, Alzheimer's disease, chronic fatigue syndrome, Epstein-Barr virus, fibromyalgia, lyme disease, myalgia or encephalitis
Have you EVER: been tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?
Other than as indicated previously, have you EVER: a. Had any medical test or surgical operation performed (including Caesarean-section) or gone to a hospital, doctor’s office, or other medical facility for observation, examination or treatment or been advised by a licensed practitioner acting within the scope of his/her license to have any medical test or surgical operation that was not performed?
b. Been advised by a licensed practitioner acting within the scope of his/her license to modify or restrict eating, drinking, or living habits because of any health condition?
c. Received medical treatment or advice by a licensed practitioner acting within the scope of his/her license for muscle weakness, unexplained weight loss of 10 pounds or more, swollen glands, visual disturbance, recurring diarrhea, fever or infection?
Are you pregnant? If YES, expected delivery Date in comments sections?
Within the last 5 years, have you taken, been advised to take or are you currently taking any prescription or nonprescription medications or over the counter herbal medications or supplements?
Have you EVER used cocaine, heroin or any other illicit drugs or controlled substances except as prescribed by a health care professional; received treatment or advice regarding the use of alcohol or drugs from a health professional or organization which assists those who have an alcohol or drug problem?