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Disability Insurance

Member Insurance Solutions > Quotes > Disability Insurance

Member Insurance Solutions offers a wide variety of insurance products designed to meet your needs. To receive your free, no-obligation quote please complete the following form. If you prefer, you may contact us by phone at 800.878.6765.

I would like to receive information by:

Mail

Phone

Fax

Personal Appointment

Email

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Best time(s) to call(Required)

Fax

Email(Required)

Please provide a quote for:

Personal Disability

Key Person Disability

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Male

Female

Height(Required)

Weight(Required)

Occupation(Required)

Have you ever used tobacco or nicotine substitutes?(Required)

Yes

No

Please explain(Required)

Is there anything significant about your health history?(Required)

Yes

No

Please explain(Required)

Do you take any medication?(Required)

Yes

No

Please provide name, dosage and frequency(Required)

Have you taken antidepressant medication or received counseling?(Required)

Yes

No

Please provide details(Required)

What is your earned income for this year?(Required)

For last year?(Required)

Are there any citations on your driving record?(Required)

Yes

No

Please explain(Required)

Do you participate in activities that might be considered hazardous (i.e., skydiving, piloting, auto racing, etc.)?(Required)

Yes

No

Please explain(Required)

Do you have disability income coverage now?(Required)

Yes

No

Provide monthly benefit amount(Required)

Please include information and a proposal on insurance to cover my business loans in the event I become disabled

Please include information and a proposal on insurance to cover my business loans in the event I become disabled

Monthly Loan Payment(Required)

Length of Loan (months)(Required)

Benefit Period (Years)

5

6

7

8

9

10

Please include coverage for my business overhead expenses

Please include coverage for my business overhead expenses

Rent

Utilities

Maintenance

Employee Salaries

Employee Benefits

Accounting/Legal Fees

Professional Dues

Malpractice Insurance

Property & Casualty Insurance

Subscriptions

Equipment Lease Payments

Postage/Stationary

Laundry

Depreciation

Other Miscellaneous

TOTAL MONTHLY EXPENSES

Waiting Period (Days)(Required)

30

60

90

180

365

Benefit Period (Months)(Required)

12

18

24

Please include coverage for my Buy-Sell Agreement

Please include coverage for my Buy-Sell Agreement

Lump Sum or Over Time(Required)

Lump Sum

Over Time

If over time, how many months?

12

24

36

48

Waiting Period (in days)

360

540

720

3657 Okemos Road, Suite 100
Okemos, MI 48864
toll-free 800.878.6765
fax 517.484.5460

Statements on this website as to policies and coverage and other content provide general information only and we provide no warranty as to their accuracy. Clients should consult with their licensed agent as to how coverage pertains to their individual situation. All coverage is subject to the terms, conditions and exclusions of the actual policy issued.

Member Insurance Solutions is a marketing name of MDA Insurance & Financial Group

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