Disability Insurance Proposal
Please complete the form below to receive your free disability insurance proposal. One of our qualified brokers will contact you in order to discuss your proposal.
Your Personal Info
First Name:
Last Name:
Address:
Apt #
City:
Province:
Postal Code:
Home Number:
Work Number:
Ext:
Fax Number:
E-mail:
Member of which association?
Association (if not listed above):
Date of Birth:
Gender:
male female
Height:
feet inches
Weight:
pounds
Do you currently have any health problems, (Back, Heart, Blood Pressure or Cholesterol)?
No Yes
Description of current health problems (if relevant)
Have you ever been treated for stress, back problems or any other illness that has or could have affected your ability to work.
Description if yes
Have you ever smoked?
yes no
If yes, when was the last time?
--Select--< 1 yr1-2 yrs2-5 yrs5+yrs
Disability Plan Design
Occupation:
Elimination Period:
Number of Days
Benefit Duration:
5 years:
To Age 65:
Partial/Residual Benefits:
Cost of Living:
Future Insurability Option:
Return of Premium:
Business Overhead Disability:
Business Buy-Out Disability:
Follow Up
Our office hours are 8:30am to 4:30pm EST Monday through Friday. Please advise when during these hours it would be most convenient to contact you?
If you would like to make any additional comments, please enter them here.
Would you like to be added to our mailing list?
Yes No