Disability Quote Request | First Insurance Agency of the Hill Country

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Personal Information

Select Your State

Please Note: We only write insurance for these states.

Address

What is your address?

Street Address Address Line 2 City ZIP Code

Name*

What is your name?

First Last

What is your telephone number?*

Email Address*

What is your email address?

Fax

What is your fax number?

What is your birth date?

What is your gender?

Male
Female

What is your height?

Height (example 5′ 8″)

What is your weight?

Marital Status

Married
Single
Divorced
Widowed

Underwriting Information

Pilot License

Do you have a pilot license of any type?

Yes
No

If Yes, What Type?

Scuba Diving, Any Racing, Mountain Climbing, Hang Gliding, Skydiving, etc

Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, etc?

Yes
No

License Suspended or Revoked

Have you had your drivers license suspended or revoked?

Yes
No

Convicted of a Felony

Have you been convicted of a felony?

Yes
No

Received Disability

Have you received disability compensation?

Yes
No

Advised to Reduce Alcohol

Have you been advised by a physician to reduce your alcohol consumption?

Yes
No

Use Tobacco

Do you smoke or chew tobacco?

Yes
No

Narcotic

Have you used LSD, cocaine or any illegal narcotics?

Yes
No

Impaired Health

Is your health impaired in any way?

Yes
No

Taking Medication

Are you taking medication?

Yes
No

High Blood Pressure

Do you have high blood pressure?

Yes
No

Respiratory Problems

Do you have asthma, emphysema or respiratory problems?

Yes
No

Cancer or Tumors

Do you have cancer or other tumors?

Yes
No

Diabetes

Do you have diabetes?

Yes
No

AIDS or HIV

Do you have AIDS; HIV?

Yes
No

Pregnant

Are you pregnant?

Yes
No

Declined Insurance

Have you ever been declined life, health or disability insurance?

Yes
No

U.S. Citizen

Are you a U.S. citizen?

Yes
No

Remarks

Coverage Information

What is your annual gross salary, including tips, fees, and commissions?

How long have you been employed at your present occupation?

What percentage of your income do you want your disability policy to cover?

50%
60%
65%
70%

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)?

Self-Employed

Are you self-employed?

Yes
No

Occupation

What is your occupation?

Duties

Please describe briefly your duties at your current job.

Reason for Purchasing

Is there a particular reason why you are purchasing disability insurance?

Yes
No

If yes, please explain.

Own Now

Do you have disability insurance now?

Yes
No

If yes, how much do you have now?

Questions or comments

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