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Disability

Long-Term disabilities can seriously affect your ability to earn an income. Disability insurance protects your most important asset, your earning ability. Insurance Answers, INC. offers a variety of services to provide you with a source of income incase you suffer a serious disability. For more information about specific disability plans, please contact Insurance Answers, INC. directly.

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Name:

Street:
City:
State:
Zip Code:
Phone:
E-mail:
Best time to call:

Gender:
Male Female
Date of Birth:
Height:ftin
Weight: lbs.
Are you a smoker?
yes no
Is the person applying currently disabled?
yes no
What is the applicant's occupation?

What is the applicant's monthly income?

Does the applicant have any health conditions or take any medications?
yes no
If so, please elaborate:


Questions or Comments: