Queen City Insurance Agency, LLC

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Disability Quote

Disability Insurance Quote

For the Fastest and most accurate quote, please provide as much information as possible. This information will be kept confidential and will be used for quote purposes ONLY!

Company Name:
Name:	Position :
Contact Name (if different):	Position :
Street Address:
City:	State: ZIP:
Email:	Fax:
Work Phone:
Please Contact me by:	When (Time)

Coverage Desired

Fill in all that you would like to see illustrated:

Monthly Benefits #

Elimination Period * 1 wk 2 wks 4 wks 13 wks 26 wks 52 wks

Length of Benefits 6 mths 1yr 2 yrs 5 yrs 10 yrs Age 65

*Period of Disability before benefits start.

Personal Information

		Fill in for additional people
Name:
Date of Birth:
Monthly Benefits:
Gender:	Male	Male	Male	Male	Male
Gender:	Female	Female	Female	Female	Female
Tobacco Use:	Y N	Y N	Y N	Y N	Y N
Height:	ft. in.	ft. in.	ft. in.	ft. in.	ft. in.
Weight:	lbs	lbs	lbs	lbs	lbs
Have you (they) had any of the following health conditions :	Heart Cancer Diabetes High BP	Heart Cancer Diabetes High BP	Heart Cancer Diabetes High BP	Heart Cancer Diabetes High BP	Heart Cancer Diabetes High BP
Occupation* :
Years of Experience:
Exact Duties*:

Are there any past or current health problems? If yes, please list name and provide details:

Is anyone currently taking any medications? If yes, please list name and provide details:

Has anyone been declined for health insurance? If yes, please list name and provide details:

Additional Comments

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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