Kent Kingsley Independent Health Insurance Broker NC Lic #10679530
For an accurate estimate of your North Carolina disability insurance we need some basic information from you in regards to your current employment status, income, and health status. Please fill in the appropriate information so we can analyze which plans to send you and to make sure you qualify for coverage.
All fields are required...quotes cannot be completed and sent without this information.
Please note that your information is kept completely confidential and is NEVER sold to anyone. This information is only used by us to provide quotes that we feel will be accurate based on the underwriting procedures of the carrier.
Coverage Requested: Disability
Last Name:
First Name: DOB: Ht: Wt: Tobacco: NY
Occupational Duties: *Please be very specific in your details and include any manual or field duties.
Income (If self employed, income is Net Income, after expenses, on Schedule C): 2 yrs ago Last Year Current Start Date
If owner, percentage ownership # Years # of Employees
Do you currently have existing disability coverage: NY If yes, is this group coverage NY and if so is this paid by the EmployerEmployee or is this individual coveage YN
Benefit Amount Requested:
Please select disability type Personal DIOverhead ExpenseBuy/Sell
Elimination Period Reqested: 30 Days60 Days90 Days180 Days365 Days
Benefit Period: 1 Year2 Years5 Yearsto age 65/67
Please provide us with any medical conditions or prescriptions that are being taken and by whom:
Home Zipcode:
Email:
Phone: