Name:
Email Address:
Your date of birth:
Your Occupation:
Best telephone number for contact:
Home Phone:
Work or cell phone:
Please let us know which disability plans you already may have:
If known, what percentage of your pay will be paid (if applicable)?:
If applicable, do you pay for the entire disability premium, or does your employer pay any portion?:
Have you calculated how much income you would receive in the event you become disabled?:
Yes
No
Not applicable (no coverage)
Do you also have a mortgage on your home?:
Yes
No
Not applicable
If you have a mortgage, do you have mortgage disability coverage?:
Yes
No
Not Applicable
If you have a mortgage covered for disability,how long would the payments be made for?:
12 months
24 months
full length of mortgage
Not sure, but would like a review to find out
Not applicable (no coverage)
Would you like to ensure your current occupation is covered to age 65, and that your income will be secured at it’s current level?:
Yes
No
Uncertain, and I need to discuss this with you
Would you say you are at the greatest risk of:
Accidental disability
Illness Disability
Risk is equal for both
Not certain
What has prompted you to look into disability insurance:
Please advise when would be the best time and date(s) to reach you, and which contact number:
