AFFIRMATIVE INSURANCE SERVICES 5624 Lankershim Blvd., North Hollywood, Los Angeles, California-91601. Phone: 818-997-7879 Fax: 818-997-7844 EMAIL: info@getais.com INSURANCE QUOTE: DISABILITY INSURANCE DISABILITY INSURANCE WORKSHEET First Name: Last Name: Address: City: State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip Code: Phone Number: Fax Number: E-Mail Address: Who Referred You To Our Site? Height: Weight: Sex: Male Female Date of Birth: Marital Status: Single Married Divorced Occupation: Are you Self-Employed? Yes No UNDERWRITING INFORMATION Do you have a pilot license of any type? Yes No If Yes, What Type: Indicate if you participate in Scuba Diving; Any Racing; Mountain Climbing; Hang Gliding; Skydiving, etc: Have you had your drivers license suspended or revoked? Yes No Have you been convicted of a felony? Yes No Have you received disability compensation? Yes No Have you been advised by a physician to reduce your alcohol consumption? Yes No Do you smoke or chew tobacco? Yes No Have you used LSD, Cocaine or Any Illegal Narcotics? Yes No Is your Health Impaired in any way? Yes No Are you taking Medication currently? Yes No Do you have High Blood Pressure? Yes No Do you have Asthma, Emphysema or Respiratory Problems? Yes No Do you have Cancer or other Tumors? Yes No Do you have Diabetes? Yes No Do you have AIDS; HIV? Yes No Are you Pregnant? Yes No Have you been Declined Life Insurance before? Yes No Are You a U.S. Citizen? Yes No COVERAGE INFORMATION What is your GROSS MONTHLY income: Amount of Monthly Benefit Coverage Desired: How many Months do you want the Benefit to Cover: Waiting Period before the Benefits begin : Is there a particular Reason Why you are Purchasing Disability Insurance? Yes No If Yes, Please Explain: Do you have Disability Insurance Now? Yes No If Yes, How Much Do you have Now? Questions or Comments to help the Agent: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.
Do you have a pilot license of any type?
Yes No
What is your GROSS MONTHLY income: