Southeast Insurance Solutions, Inc.
Southeast Insurance Solutions, Inc.
2137 Chatham Avenue
Charlotte, NC 28205
Phone: 704-560-8972
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North Carolina Disability Insurance Quote


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:   

Last Name: 

First Name:     DOB:    Ht:   Wt:   Tobacco:

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:    
   If yes, is this group coverage  and if so is this paid by the  
   or is this individual coveage   

Benefit Amount Requested:   

Please select disability type  

Elimination Period Reqested:   

Benefit Period:

Please provide us with any medical conditions or prescriptions that are being taken and by whom:

Home Zipcode:       



Southeast Insurance Solutions, Inc.
2137 Chatham Avenue
Charlotte, NC 28205