Dentist Disability Insurance Quotes

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First Name

Last Name

Cell Phone

Date of Birth

Primary Email

Gender

State of Residence

Zipcode

Citizenship Status

In which country are you a citizen?

What type of Visa/Green card do you have?

What is the frequency and duration of your travel outside of the U.S.?

Speciality

Current Occupation Status

Current Employment

Current Annual Income:

Name of Dental School

Dental School End Date

Employer Name

When did you graduate from your training program?

If you finished your training program in the last 12 months, what was the program/institution name?

Resident Program Sponsor/Institution:

Residency End Date:

Expected Annual Compensation in Residency

Are you currently covered by a group disability plan?

Current Group Disability Monthly Benefit Amount:

What percentage of your income does the current group disability plan cover?

Does your employer pay the premiums for the group disability plan?

New Employer

Do you have plans to change employers? Have you signed an employment contract yet?

Expected Annual Compensation:

New Employer Name

New Employer City

New Employer State

New Employer Start Date

Is group disability insurance provided?

New Employer Group Disability Monthly Benefit Amount:

What percentage of your income does the new group disability plan cover?

New employer pay DI premium

Health & Hobbies

Height

Weight

Do you have any medical conditions?

Please list all medical conditions

Do you currently take any medication(s)?

Please provide the name, dosage, purpose, and length you have been taking each medication

Within the past 10 years, have you been hospitalized or undergone any surgery?

Please list all hospitalizations or surgeries undergone within the past 10 years.

Do you engage in any high risk hobbies or activities?

Please list all High Risk Hobbies/Activies:

How did you hear about us?

Moving Soon?

Are you moving to a new state in the next 4 weeks?

Which State will you be moving to?

Additional Information

Are you interested in your life insurance options?

Feel free to provide any additional Comments or Questions.

What name do you like to go by?

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Not Sure if You Need Disability Insurance?

The greatest investment you have made is in your training. The greatest financial asset you will probably ever own is the return on that investment: your career income. Protect your most valuable asset with true, own-occupation disability insurance.

You would insure a car that is worth $30,000 and a house that is worth $250,000. Shouldn’t you insure your career income which could be worth worth tens of millions of dollars?

Disability Insurance Facts:

1 in 4 Americans in the workforce will suffer a disabling injury before retirement
350,000 bankruptcies per year can be attributed to unexpected injuries or illnesses
65% of applicants for disability benefits through Social Security are denied the first time