RJ Insurance Services
At Your Service
Disability Insurance Form
Introduction to Disability Insurance | Disability Insurance Quote | Disability Links
Please complete the following information if you would like
to obtain a quote on Disability Insurance. Please understand
this is not an application for insurance. An application will be
sent to you if coverage is desired.
Personal Information
First Name:
Last Name:
Initial
Street Address
City:
State
Zip
Your phone
number
Your email address:
Date of Birth
Sex
Height
Weight
Do You Smoke?
What is your annual
gross salary?
Are you a U.S. Citizen?
Coverage Information
How long do you want the
elimination period to be
(the length of time you
must be disabled before
you start to receive
benefits)?
How long do you want the benefit
period to be (the maximum length
of time you will receive benefits
after you have been classified as
being disabled and satisfied the
elimination period)?
Are you currently employed?
Are you self-employed?:
What is your occupation?
Describe Job Duties:
How long at your present
job?
Underwriting Information
Do you have a pilot license
of any type?
If yes what type?
Do you participate in
scuba diving, any racing,
mountain climbing, hang
gliding, skydiving, etc?
Have you had your
drivers license
suspended or
revoked?
Have you been
convicted of a felony?
Have you been advised by
a physician to reduce your
alcohol consumption?
Have you received
disability
compensation?
Have you ever been
declined life, health
or disability
insurance?
Is your health impaired in
any way?
Do you have high
blood pressure?
Do you have cancer
or other tumors?
Do you have asthma,
emphysema or respiratory
problems?
Do you have
diabetes?
Do you have AIDS;
HIV?
Are you taking medication?
Are you pregnant?
Have you used LSD,
cocaine or any illegal
narcotics?
Additional Information
Please let us know the
best time to call and
discuss your quote
Comments/Questions
All information provided on this information sheet is confidential and will be used solely for the purpose of
developing a quote for you.