General Information:

 

 

Disability Insurance provides a preset income to an insured person who is unable to work due to injury or illness income payments to an insured wage earner when income is interrupted or terminated because of illness, sickness, or accident.

1.  *First Name:  
2.  *Last Name:  
3.  *Phone:  
4.  *Email:  
5.  Address:  
6.  Address:  
7.  City:  
8.  *State:  
9.  *Zip Code:  
9.  County:  
We'll begin by asking for a little information about you. Your answers to the following questions will enable us to determine whether long term care is a wise choice for your present and future insurance needs.
1) Have you used any form of tobacco or nicotine substitute in the past five years?
2) If Yes, what forms of tobacco did you use? Smoke Cigarettes
Smoke Cigars
Smoke A Pipe
Chew Tobacco
Chew Nicotine Gum
'The Patch'
3) If you are currently a cigarette smoker, how many packs per day do your smoke?
4) Have you used any form of alcohol in the past five years ? Yes No
5) If Yes, do you drink: Beer
Wine
Liquor
6) Have you received a DUI Or DWI in the last five years? Yes No
7) Have you been hospitalized in the last five years? Yes No
8) Are you currently taking any prescription medications? Yes No
9) Are you a U.S. citizen? Yes No
10) Have you lived outside the United States anytime during the last three years? Yes No
11) In the future, do you plan to leave the United States for travel or change of residence? Yes No
12) To your knowledge, is there a history in your family (grandparents, parents or siblings) of cardiovascular disease before the age of 60? Yes No
13) During the last 2 years, have you worked in any type of hazardous, occupation? (for example underground mining, high-rise construction, work or explosives handling) Yes No
14) Are you an active member of the military or military reserve?
15) Have you flown on an aircraft as a pilot, co-pilot or crew-member, within the last three years?
16) Do you participate in any risky activities such as racing, scuba, diving, sky diving, mountain climbing, para-sailing or ultra light, flying? Yes No
17) Have you had any health symptoms relating to the conditions listed below? (If yes, please check the box next to the specific condition(s) listed below that you have been told you had or have been treated for)
Central Nervous System Skin, Bones or Muscles Mental Health, Drug Abuse
Epilepsy
Multiple Sclerosis
Alzheimer's Disease
Cancer 		Rheumatoid Arthritis
Melanoma
Cancer 		Alcoholism
Drug Abuse
Mental Illness
Depression
Digestive System Respiratory System Circulatory System
Chronic Kidney Disease
Liver Disease
Kidney Stones
Gastric/Peptic Ulcers
Ulcerative Colitis or Ileitis
Neurogenic Bladder
Bowel Incontinence
Diabetes Mellitus
Cancer 		Asthma
Emphysema
Chronic Bronchitis
COPD
Cancer 		Coronary Artery Disease
Vascular Disease
High Blood Pressure
Stroke
Elevated Cholesterol
Cancer
HIV
The answer to these basic questions will help us process your information.
18) What range best describes your approximate household income:
19) Do you own or rent your residence:
20) Time at current residence:
21) Please describe your credit history:
Please answer these last few questions, and we'll begin our search for the most suitable insurance policy for you. We'll deliver our search results to your desktop immediately, and you will receive a customized quote from an AllInsuranceNeedz.com participating agent within just 24 hours.
About You
22) Best Time To Contact:
23) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

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