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Disability Quote Request

Submission Routing

Please Enter Your Location Information Below:

Producer Information

(please include your area code.)
(please include your area code.)
All proposals and product information will be sent to you by email unless we are instructed otherwise.

Client Information

Birth Date:
Tobacco or Nicotine Use:

Medical Information

Has there been any weight change of more than 10 lbs in the last year?
In the last ten years, has your client been treated for or been diagnosed as having: (please check all that apply)
Please enter details for any box checked

Employment Information

Work out of Home?
Does the prospect own his/her own business?

BOE Coverage

Would you like a proposal for Business Overhead Expense coverage?
What form of business?

Buy/Sell Coverage

Would you like a proposal for Disability Buy Sell coverage?
Lump Sum:
Monthly Funding


(Income after business expenses but before taxes)
Do you want to see a retirement plan protection product proposal?
Has the Bonus or Commission been consistent for the last 3 years?


Does the prospect have ANY other disability benefits (including Group STD or LTD)?


DESIRED ILLUSTRATION INFORMATION: (Not all carriers provide all benefits or options or make them available to all risk classes - we will attempt to match your quote as closely as possible to your request)

Short Term Disability

Elimination Period:
Benefit Period:
Product Requested:

Long Term Disability

Elimination Period:
Benefit Period:
Product Requested:
Optional Provisions:
(Not all riders are available on all products)

Carrier Selection

Would you like us to recommend a carrier we feel provides the best value?
(If you select NO, multiple quotes will be provided)

Disability Quote Request
Savage Bowling Green

1224 W. Wooster Street, Suite C
Bowling Green, OH 43402
(p) 419.353.1885
(f) 419.353.3694

Savage Toledo

655 Beaver Creek Circle
Maumee, OH 43537
(p) 419.475.8665
(f) 419.475.8240

Savage Findlay

2498 Bluestone Drive, Suite A
Findlay, OH 45840
(p) 419.420.9049
(f) 419.420.9019

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