Date of Birth:
Has the proposed insured ever used any form of tobacco or nicotine-based products, or substitutes such as patches or gum?
If "Yes", date of last use:
Is the proposed insured a United States citizen, or does the proposed insured have permanent (green card) status?
State of Residence:
Is the proposed insured self-employed?
Is the proposed insured a government employee?
Occupation Class:   (click here to determine)
Monthly Income:
   (specify "gross" if not self-employed or "net" if self-employed)
Is the proposed insured currently working at least 30 hours per week in their primary occupation?
Monthly Disability Income Benefit:
   (pre-filled with maximum benefit; you may input lower amount)

Need Advice?
Dave recommends choosing an amount equal to 60% to 70% of your monthly income which can be reduced based on your progress with debt and savings.

For more information click
Benefit Period: Need Advice?
Dave recommends a minimum of at least a five year benefit period and longer if your budget can afford it.

For more information click
Elimination Period:
Need Advice?
Dave recommends taking the longest elimination period your budget and emergency fund can afford.

For more information click
* First Name:
* Last Name:
* Personal Phone Number:
 -   - 
* E-mail Address:
* not required