B & M Insurance Agency, Inc.

591 North Avenue, Door B, 1st Floor
Wakefield, MA 01880

Phone: 781-245-0007     Fax: 781-245-2348

Please be advised that insurance coverage cannot be bound, modified, or terminated by e-mail messages or information provided to us via the web. Any information you submit will be used solely for the purpose of quoting insurance options, and does not in any way constitute an agreement of coverage.

Disability Insurance Quote

Full Name: Email:
Mailing Address: City:
Street Address: (if different) State: Zip:
Home Phone: (with area code)
Work Phone: (with area code)
Ext:
Fax: (with area code)
Best time to contact:
  1. Are you currently insured for disability?

    Yes No

    If yes, please list company:

  2. What is your occupation? Please list

    For how long?

  3. Do you have a second job?

    Yes No

    If Yes, please list job and for how long employed?

  4. List your gross income level, ncluding bonuses

  5. Have you ever made a claim for disability?

    Yes No

    If Yes, please provide details:

  6. What percentage of your salary would you like to receive in payments (benefits)?

  7. For what length of time do you wish disability insurance to pay?

  8. Select a waiting period before benefits would be received.

  9. Please check all medical conditions that apply

    Heart
    Lungs
    Kidneys
    Back/spine/neck
    Knees
    Cancer
    Diabetes
    AIDS
    Hepatitis
    Epstein/Barr
    Other

    If Other, please list:

  10. Questions and/or comments:

Important Note: Quotes will be based on the information provided. It is only a rate calculation and is not binding in any way. A full application must be completed and signed by the named insured.