Prime Insurance Group - Group Disability Quote

Group Disability Quote

Group Disability Income Quote Request

Full Name:

Daytime Telephone:

Company Name:

Evening Telephone:

Street Address:

Fax:

City, State & Zip:

Best Time To Reach You:

E-Mail Address:

Type of Business/Industry:

Current Insurance Information

Disability Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/A)

Group Census
(If More Than 10 Employees, please call us to receive a large group census form.)

List employees' required census data:

Employee #1	Occupation: Salary: $ Age: Male Female
Employee #2	Occupation: Salary: $ Age: Male Female
Employee #3	Occupation: Salary: $ Age: Male Female
Employee #4	Occupation: Salary: $ Age: Male Female
Employee #5	Occupation: Salary: $ Age: Male Female
Employee #6	Occupation: Salary: $ Age: Male Female
Employee #7	Occupation: Salary: $ Age: Male Female
Employee #8	Occupation: Salary: $ Age: Male Female
Employee #9	Occupation: Salary: $ Age: Male Female
Employee #10	Occupation: Salary: $ Age: Male Female

Coverage Information:

When Do You Want Your Disability Policy to Begin?
Choose Wating Period: (The time that will elapse before your disability payments begin)		30 Days 60 days 90 days 180 days 265 days
Choose Benefit Period: (The amount of time you will receive benefits for)		1 Year 2 Years 3 Years 5 Years To Age 65
Tell Us What You Want MOST in your Group Disability Plan, or list any other Remarks here:

Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form

We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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