Disability Insurance Quotes

Thank you for coming here to complete the next step after submitting the form at whitecoatinvestor.com.

Our goal is simple: To get you the most complete set of proposals for disability insurance.

By completing the form at this page, we will have all the information that we need to prepare disability insurance proposals for you. We will be able to research discounts and find the policy that is ultimately best for you. It will take about 2 minutes to complete the form.

We appreciate the opportunity to serve you and your family. Thank you.

First Name: *

Last Name: *

Gender *

Male

Female

Email Address: *

Phone Number *

Date Of Birth

Date of birth - Month

Date of birth - Day

Date of birth - Year

State of Residence *

Do You Currently Use Tobacco Products?:

Yes

Details for "Tobacco Use"

Are you a member of the US military?

Yes

Other (details)

Rank

Date for enlistment (approximate date is fine for purposes of applying for disability insurance)

Date of separation from the military, if known

Are you receiving disability benefits from the military?

Yes

Details for military disability

Please indicate the amount and "percentage" you receive from the military disability program. What is the disability from (tinnitis, etc)?

Occupation *

What is your occupation? *

Description of Occupational Duties

Career Stage (at this moment):

Dental Student

Resident

Fellow

Practicing - Employee

Practicing - Business Owner / 1099

Career Stage (at this moment): *

Medical Student

Resident

Fellow

Attending - Employee

Attending - Business Owner / 1099 / Locum Tenens

Annual Income: *

Annual Income

We understand that as a medical/dental student, there is no base income that is paid to you. Feel free to detail any income you have from other sources.

Breakdown of compensation (military personnel only)

Compensation Type

Compensation ($)

Add Remove

Employment Type

W2 / Employee

Business Owner / 1099

Combination of W2 & 1099

Details for "Combination of W2 & 1099"

Accountant - Which applies to you (select highest level) *

Certified Public Accountant (CPA)

Bachelor's Degree

Engineer - Field of Study/Work *

Engineer - "Not Listed" - Field of Study/Work *

Engineer - Which applies to you (select highest level) *

PhD

Bachelor's Degree

Other

None

Engineer - Do you have a Professional Engineer (PE) credential? *

Yes

Engineer - Do you perform manual duties in your work? *

Yes

Employer Name *

"Other" Employer Name *

Specialty (or specialties if more than one) *

Specialty (Other) *

Anticipated Specialty *

Residency Program (at this moment):

"Not Listed" Residency Program *

Do you plan to do a fellowship after residency is completed? *

Yes

Not sure

Future fellowship details (sub-specialty, location, hospital, etc.) *

Fellowship Program (at this moment):

"Not Listed" Fellowship Program

Medical School Program *

"Not Listed" Medical School details *

Which Dental School do you attend?

Which Dental School did you attend?

In what month do you intend to complete training? *

In what year do you intend to complete training? *

In what month did you complete training?

In what year did you complete training?

Board Certification(s) if any, or anticipated:

Do you have any disability insurance outside of what is provided to you through your current program?

Yes, I purchased an individual policy

No, I only have the group coverage provided through my program

No, I do not. I also do not have any group coverage in place through my program

Most programs provide group disability insurance with the standard package of benefits. Note that this group coverage, if in place, will not be factored in to the underwriting decision because of special programs for medical and dental professionals, while in school/training.

Details? (Carrier, Amount, Status)

Do you have group disability insurance in place now?:

Yes, I have group coverage in place

No, I do not have group coverage in place

Details of existing group disability insurance

Do you know what the monthly max benefit is for your group coverage?

Please enter dollar amount (ie. $10k, $15k, $25k monthly, etc. This would be in your plan document or you can obtain from the benefits department. Please feel free to send this information along later if you do not know what it is while completing this form.

Do you have individual disability insurance in place now?

Yes, I have individual coverage in place now

No, but I am currently in underwriting for a policy

No, I do not.

Which company is your individual disability insurance with?

"Other" Details

Monthly benefit for existing individual disability insurance policy? (Please estimate if you do not know the exact amount)

Attach any group or individual policy that you have. Also feel free to attach any quotes or plan details that you are reviewing. (Optional)

Maximum file size: 20MB

Do you work at least 30 hours per week?

Yes

How many hours do you work per week?

Do you own a business or practice?

Yes

Do you plan to own a Practice, to buy in as a Partner, or will you be thinking about a startup at any point in the next year or so?

Yes

Do you plan to own a business in the next year or so?

Yes

Approximate monthly Business Expenses during a period of disability?

It is important to "match" the "right" disability product to the need. We will quote business overhead disability insurance with your individual quotes. The benefit from the individual policy is for you and your family. The benefit from the business insurance is to pay rent, utilities, payroll, etc. while you are out.

Do you anticipate borrowing for your business for real estate transactions, equipment loans, working capital, for starting a business, or for debt consolidation within the next 3 years?

Yes

Do you have a signed employment contract for after training is over?

Yes

Signed employment contract details (income, start date, does it include group disability insurance benefits, etc.)

Would you like to receive quotes for life insurance?

Yes

Life Insurance Face Amount:

Please enter a number between 50000 and 100000000

Term Length (select multiple if you want laddered life insurance) *

5 year level term

10 year level term

15 year level term

20 year level term

25 year level term

30 year level term

35 year level term

40 year level term

Other

General comments for life insurance (replacing other coverage?)

General non health related comments for disability proposals (Please use our "Step 2" right after this for any health history/concerns you would like to discuss)

Who referred you to us?

What did you search for?

"Other" details (we appreciate any feedback that you might have)

Separate from (or part of) the work we do with you to review options for insurance, would you be open to helping coordinate a group presentation to your residency program?

Yes, would love to discuss an in person seminar

Yes, would love to discuss a phone or video based seminar

No thank you.

Please let us know what we can do to accommodate your group?

Desired Date for Webinar

Desired Time for Webinar

General File Attachments (Optional)

Maximum file size: 20MB

Please feel free to attach anything that you believe we should review as part of putting proposals together for you.

Please check here if you have some medical conditions or history which you worry may impact a disability policy. And/or if you feel that you have any other 'unique' circumstance that might be a concern.

Yes

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Guaranteed Renewable Non-cancellable

Yes

Quoted with a discount?

Discount quoted

Add Remove

Disability Insurance Quotes

Insuring Income specializes in providing Disability Insurance Quotes. We look forward to helping you with this.

Breakdown of compensation (military personnel only)

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