Address (include city and zip):
# Of years in this Occupation:
Briefly describe exact job functions:
Date of Birth:
Would you like a quote for the benefits payout to be short term (2 years) or long term (until age 67) or both:
The usual waiting period before payouts begin is 90 days after your injury. Would you like to pay a higher price to have your payout start sooner?
Monthly payout you would like?
Would you like us to quote the maximum payout available?
Is your disability policy to help cover your business exposure, or is it just personal.
Work less than 30 hours a week:
Net annual income after taxes on last tax filing:
Self employed or own 25% or more of a business:
# of Empolyees you have:
Any individual, or group disability, or business overhead coverage in force now:
Are you covered by State Disability Insurance currently:
If you work at home, what percent of your job do you perform at home:
Medication currently taken:
If yes, type:
Employee of county, state, federal, government entity or school:
Any tobacco products used in the last 12 months:
If used ever, how many years since last used:
List hazardous occupation or hobbies:
Any special health or underwriting considerations?
Premium to be paid by:
Any questions or comments?
Doctor & Doctor Insurance Agency
10216 Reseda Blvd, Northridge, CA 91324
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