Step 1: Personal Information

Name

Email

Phone Number

Date of Birth

Gender Male Female Other

Back Next

Step 2: Coverage Preferences

Coverage Type

Short-Term Disability Insurance Long-Term Disability Insurance Own-Occupation Disability Insurance Any-Occupation Disability Insurance

Back Next

Step 3: Coverage Amount

Desired Monthly Benefit

Benefit Period 2 years 5 years Until retirement age

Elimination Period 30 days 60 days 90 days

Back Next

Step 4: Add-Ons

Add-Ons

Cost of Living Adjustment (COLA) Future Increase Option Partial Disability Rider

Back Next

Step 5: Budget

Annual Premium Budget Less than $500 $500 - $1,000 $1,000 - $2,000 More than $2,000

Back Next

Step 6: Health Information

Do you smoke?

Yes No

Do you have any pre-existing medical conditions?

Yes No

Back Finish