Long Term Disability Insurance
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Please complete the following to receive a comparison of up to four different disability insurance plans. All information provided on this sheet is confidential and will be used solely for developing a quote for you. As the sole owner of the information collected on this site, MedicalDi will not sell, rent or share this information with any third party for any reason whatsoever.
1. What is your gender? *
Male   Female
2. Do you currently have disability insurance? *
Yes – Individual Plan
Yes – Group Plan
3. What is your medical / dental specialty? *
4. What is your employment status? *
Nurse Practitioner
Clinical Nurse Specialist
Physician Assistant
Employee (of a physician group, dental group, hospital, etc)
Government Employee (City, State or Federal)
Partner of a Group
Solo Practice
Independent Contractor / Locum Tenens
Resident Physician / Fellow
Medical or Dental Student
5. What is your approximate income? *  
Under $50,000
$50,000 - $100,000
$100,000 - $150,000
$150,000 - $200,000
$200,000 - $250,000
$250,000 - $300,000
$300,000 - $350,000
$350,000 - $400,000
$400,000 - $450,000
$450,000 - $500,000
Over $500,000
6. What is your ZIP Code? *
7. In the past 12 months, have you used any tobacco products? *
Yes   No
8. What is your date of birth? *
9. What is your email address? * No Junk Mail
10. What disability insurance provisions are important to you? (check all that apply)
Own occupation definition of disability
Guaranteed option to increase my monthly benefit in the future
Inflation protection (COLA)
Partial disability benefits (Residual Benefit)
Guaranteed renewable and non-cancelable
Insurance company with high financial strength ratings
Unsure – Please provide all options
11. Would you like customized quotes from the industry’s leading providers of Life Insurance:
Yes   No
12. Please describe, in detail, any additional requirements you may have for this disability insurance plan.




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