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REQUEST QUOTE - STEP 1
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,
LegalDi will not sell, rent or share this information with any third party for any reason whatsoever.
1. What is your gender? *
Male
Female
2. Do you currently have disability insurance? *
No
Yes – Individual Plan
Yes – Group Plan
Unsure
3. What is your employment status? *
Attorney - Speciality
Paralegal
Court Reporter
Judge
Mediator
Legal Secretary
Other :
4. What is your approximate income? *
5. What is your approximate income?
*
Why we ask this
The maximum amount of coverage available is determined by annual income*.
Please list your salary and any bonus income if you are an employee or your net (after business expense and before tax) income if you own your own practice. At the time of application, the insurance company will request pay stubs and/or tax returns to verify income.
*Physicians in the first year of their own practice, medical residents, medical students and dental students qualify for a special benefit amount that is not determined by income. If you fall into one of these categories, please indicate so in the comments section.
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
5. What is your ZIP Code? *
6. In the past 12 months, have you used any tobacco products? *
Yes
No
7. What is your date of birth? *
8. What is your email address? *
9. 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
10. Would you like customized quotes from the industry’s leading providers of Life Insurance:
Yes
No
11. Please describe, in detail, any additional requirements you may have for this disability insurance plan.
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