Insure The Heroes Inc Disability Insurance Pricing

What state are you located in?* This field is required.

Do you have employer disability coverage?* This field is required.

YESNO

Does your employer pay for this benefit?

YESNO

If so, please list the the percentage of income and monthly benefit cap.

Do you have current disability coverage outside of work?* This field is required.

YESNO

If so, please list the benefit amount, benefit period and elimination period.

Wil this insurance replace any existing insurance?* This field is required.

YESNO

How do you prefer to pay premiums?* This field is required.

Monthly

Annually

Have you applied for life, LTC, disability or health insurance within the last year? * This field is required.

YESNO

Have you ever been declined disability coverage? * This field is required.

YESNO

Does your occupation require you to travel more than 25% of the time?* This field is required.

YESNO

Are you a W2 Employee?* This field is required.

YESNO

How many hours per week do you spend working from home?

How many hours per week do you spend working from an office?

What best describes the amount of physical work in your current job?* This field is required.

High

Moderate

Low

Please list your job duties and the % of time spent on each duty:

Are you a government employee?* This field is required.

YESNO

Are you a business owner?* This field is required.

YESNO

Do you work in healthcare or a dental field?* This field is required.

YESNO

How long do you want coverage locked in for?* This field is required.Choose all that you would like to see quotes for!

3 Months

6 Months

12 Months

2 Years

5 Years

10 Years

To Age 65

To Age 70

Lifetime

I am not sure, help me decide

How soon after a disability do you need to receive replacement income? * This field is required.This is known as an Elimination Period. The shorter the timeframe the higher the cost of insurance.

14 Days

30 Days

60 Days

90 Days

180 Days

365 Days

730 Days

Annual Base Income/Salary (before taxes)* This field is required.This can be your hourly rate multiple by the number of weekly hours or your annual salary.

Annual Bonus/Distributions

Other "Unearned" Annual IncomeA few examples are your spouse's income, alimony, monthly rental property income or other source of income.

Please list any degrees, professional licenses and designations:

What is your marital status?* This field is required.

Never Married

Married

Divorced

Separated

Widowed

How many dependent children are in your household?* This field is required.

Estimated monthly expenses* This field is required.Housing, car payment & expenses, food(groceries or dining out), utilities, cell phone/internet, loan & credit card, savings, other expenses(child care, insurance, clothing, etc..)

Gender* This field is required.

Male

Female

Date of birth* This field is required.

How tall are you?* This field is required.

What is your current weight? Have you lost more than 10lbs in the past year(other than pregnancy or diet/exercise)?* This field is required.

Have you used any of the following forms of tobacco or nicotine in the past 12 months* This field is required.

Cigarette

Nicotine patch/gum

Vape

Chew

Cigar

Smokeless tobacco

Marijuana

None

Please list the frequency you use any tobacco/nicotine products, incl. marijuana.

List all physical health conditions you have, what year they were diagnosed and the severity(mild, moderate or severe).

List all mental health conditions you have, what year they were diagnosed and the severity(mild, moderate or severe).

List all currently prescribed medications(even if not taken).

If you had prior medications list all prescriptions within the last 5 years.

List any surgeries in the last 5 years.

Are you currently a U.S. citizen or permanent resident?* This field is required.

Yes

Do you participate in dangerous hobbies such as aviation, scuba diving, rock climbing, racing, etc..* This field is required.

Yes

Choose your occupation type.* This field is required.

Military(Active)

Veteran/Retired Military

Homemaker

Other Professional

Retired

Business Owner

Unemployed

Are you involved in any aviation for either employment or pleasure as a pilot or crew member?* This field is required.

YESNO

Full Name* This field is required.

First Name

Last Name

Phone Number* This field is required.

Area Code

Phone Number

Are you comfortable receiving text messages at the above phone number?* This field is required.

YESNO

E-mail* This field is required.

I understand this form submission is NOT an application for coverage and that coverage CANNOT be bound by this entry. This is for a quote ONLY.* This field is required.Please call Melissa Schreur directly if you are in need of immediate assistance (571)386-2519

YESNO

What insurance plans would you like to review? Can be now or in the future!As an independent insurance broker my goal is to help you shop around while filling the gaps in your coverage. Please check all boxes that you know you need to review within the next year. I will send you the appropriate forms to get competitive quotes.

Life - Term and/or Lifetime, Burial, Child Plans

Disability - Individual, Protect Your Paycheck

Dental, Vision, Hearing - Can be individual or combined together

Hospital Indemnity Plans - Reimbursement for hospital stays, ambulance, emergency room

Critical Illness - Cancer, Heart Attack, Stroke, etc…

Personal Insurance - Home, Auto, Recreational Vehicles, Personal Items, Liability, etc...

Annuities - 401 Rollover, Retirement planning, Safe Money Accounts(Upside Potential w/o the downside risk)

Business Owners - Buy Sell Agreement, Key Employee Coverage, Employee Benefits - Life, Accident, Hospital, Cancer, etc…

Business Owners Disability - Business Overhead Expense Coverage, Key employee

Commercial Insurance - Workers Comp, Auto, General Liability, Cyber Liability, etc...

Insure The Heroes Inc Disability Insurance Pricing