Disability Buy-Out Request Form
Fields marked with an asterisk (*) are required.

In order to obtain a quote please fill out the following form and click "SUBMIT" below. We will automatically receive your information and begin working on your quote immediately. If you would like to discuss the quote request with us, please contact our office.

All questions on this form pertain to the person proposed for coverage. If more than one, please send separate forms for each person to be covered under the Buy-Out Agreement and indicate their share (%) of the Buy-Out Benefit Amount.
Name*:
E-mail Address*:
Phone Number:
Fax Number:
Business Street Address:
City:
State*:
Zip Code*:
Occupation*:
Sex*: Male     Female
D/O/B*:
(mm / dd / yyyy)
/ /
Buy-Out Benefit Amount *:
$
Elimination Period*: (Waiting Period before Benefit is Paid)
 12 Months 18 Months
 24 Months
How is Benefit to be Paid?*:
 24 Months 36 Months
 60 Months Lump-Sum
Any Health Problems?*:
Nicotine User?*: No     Yes
How would you like to be contacted?
 Postal Mail Email Fax
Additional Information:
Would you like a
specialist to call you? 		Yes No
 

 

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