1. What is your gender? *
Male
Female
2. Do you currently have disability insurance? *
No
Yes – Individual Plan
Monthly benefit amount:Replacing Adding to Unsure
Yes – Group Plan
Maximum monthly benefit amount - if known (ie. 60% to $10,000/mth):Yes No Unsure
Unsure
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)
Partner of a Group
Solo Practice
Independent Contractor / Locum Tenens
Resident Physician / Fellow
Medical or Dental Student
Other
The maximum amount of coverage available is determined by annual 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. What is your ZIP Code? *
7. In the past 12 months, have you used any tobacco products? *
Yes
No
8. What is your date of birth? *
9. What is your email address? *
Why we need your email address
In order for us to provide you with customized disability insurance quotes, you will be asked details about your purchasing requirements as well as contact information including your email address.
Your information is confidential and will be used solely for the purpose of developing a quote for you. As the sole owner of the information collected on this site, DoctorDisability will not sell, share or rent this information to third parties for any reason whatsoever.
10. 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
11. Would you also like life insurance quotes?
Yes
No
12. How did you hear about us?
Search Engine
Magazine
TV
Radio
Referral
Other
13. Please list any associations to which you belong (discounts may apply), any health history and/or comments.
