Request Quotes

Please complete the following to receive a comparison of up to four different disability insurance plans. All information provided on this sheet is confidential and will be used solely for developing a quote for you. As the sole owner of the information collected on this site, disabilityincomefordoctors.com will not sell, rent or share this information with any third party for any reason whatsoever.


1. What is you gender? Male Female
2. Do you currently have disability insurance? *
No Yes - Individual Yes - Group Plan Unsecure
3. What is your medical / dental specialty (please indicate if interventional or diagnostic)? *
4. What is your employment status? *
Employee (of a physician group, dental group, hospital, etc)
Government Employee (City, State or Federal)
Independent Contractor / Locum Tenens
Resident Physician / Fellow
Year and Program Name:
Medical or Dental Student
Other
5. What is your approximate income? *
Under $50,000 $50,000 - $100,000
$100,000 - $150,000 $150,000 - $200,000
$200,000 - $250,000 $250,000 - $300,000
$300,000 - $350,000 $350,000 - $400,000
$400,000 - $450,000 $450,000 - $500,000
Over $500,000  
6. In the past 12 months, have you used any tobacco products? *
Yes No
7. What is your date of birth? *
8. What disability insurance provisions are important to you? (check all that apply)
Own occupation definition of disability
Guaranteed option to increase my monthly benefit in the future
Inflation protection (COLA)
Partial disability benefits (Residual Benefit)
Guaranteed renewable and non-cancelable
Insurance company with high financial strength ratings
Unsure – Please provide all options
9. Would you also like life insurance quotes? * Yes No
10. How did you hear about us?
Search Engine Magazine TV
Radio Referral Other
11. Please list any associations to which you belong (discounts may apply), any health history and/or comments.
12. Salutation: *
13. First Name: *
14. Last Name: *
15. Email Address: *
16. Work Number:
17. Home Number:
18. Best Contact
Location/Time:

19. Street Address: *
20. City: *
21. State/Zip: *
  Enter code: * verify
  * mandatory.