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Disability Insurance Quotation Request

To receive a free confidential disability insurance quotation, we need to know something about you so that an insurance company can evaluate your risk factors.  This being the case, please provide us with the information requested below.

Medical Management and Kaplan Management respects your right to privacy.  The information you provide will never be sold or shared with any organizations.

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First Name:

Middle Name:
Last Name:
Are you self-employed?:
Are you married?:
Date of Birth:
State of Birth:
US Citizen?:
Do you use tobacco? ie. cigars, pipe or cigarettes?:
If yes, how often:

What is your occupation? (Describe your duties):                                                                   

Please list below any pre-existing Medical Conditions and any medications that you have been prescribed  within the last five years:

Current Year Earned Income: $
Prior Year Earned Income: $
Earned Income, 2 Years ago:  $
Earned Income, 3 Years ago:  $
When do you finish your training?
Are you planning a fellowship?  
Where are you planning to do a fellowship?  
Are you a government employee?  
Do you perform any manual duties?
Do you supervise employees? 
% of time in office: 
What is your residence address?: (Do not use a P.O. Box please)
Street Address:  
Apt./Unit/Condo #: 
State :
Zip Code:
E-mail Address:
Residence phone:
Cellular Phone: 
Pager Phone:
Fax Number:
Preferred Number:
What Monthly Benefit do you want us to quote?  


What Elimination Period do you want us to quote?
What Benefit Period do  you want us to quote?
What riders do you want to include in your quote?     
  Residual                             Cost of Living                        Future Insurance Option
  Automatic Increase             Return of Premium             Group Disability Replacement
  Unemployment Premium Waiver             Catastrophic Disability          Retirement Protection 

Additional Information or Comments:

How did you hear about us?

If you have any interest in any of our other services, check the boxes below
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Thank your for your request. We will contact you soon.

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Copyright 2001 Kaplan Management & Insurance Services
Last modified: April 11, 2017