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Disability Insurance

TermUSA has partnered with Robert J. Peterson, CLU of Guilford, CT for disability insurance. Bob has over 30 years as a nationally recognized expert in Long Term Disability Insurance. He spent many years as a award winning manager with one of the industry's leading companies.

Since going out on his own, Bob has become an industry leader in high volume and hard to place cases. Bob represents the leading DI companies in the industry and will make sure you receive the best policy and underwriting consideration based on your occupation and health.

If you would like to discuss your disability needs, please complete the form below and Bob will be in touch within 24 hours.

1. Personal Information First Name Last Name Address City State -- Please Select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Daytime Telephone ( ) - Evening Telephone ( ) - Best Time to Call -- Please Select -- Anytime Morning Afternoon Evening Email Address Gender -- Please Select -- Male Female Birthday Month Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Height Feet 4 5 6 7 Inches 0 1 2 3 4 5 6 7 8 9 10 11 Weight lbs. Tobacco Use Never Used None in Last 3 Years None in Last 5 Years Current Tobacco User Occasional Cigar or Pipe Do you participate in any hazardous activities? Yes No If yes, please describe: Marital Status -- Please Select -- Married Single Number of Dependants 2. Occupational Questions Occupation Type of Business Specialty Job Duties Annual Income?   How long in this occupation? Self-Employed? Yes No If yes, Number of employees? Do you work for the government? Yes No Do you work at home? Yes No If yes, what percent of the time? Do you travel? Yes No If yes, what percent of the time? Do you currently have an individual disability policy? Yes No If yes, please enter name of company Monthly Benefit Do you have a short-term or long-term disability benefit through work? Yes No If yes, please enter number of weeks Weekly benefit

3. Medical History 1. Have you ever been treated for any of the following? (check all that apply) AIDS/HIV Hyptertension Alcohol or Drugs Kidney Disease Alzheimers Liver Disease Anxiety Mental Illness Asthma Pulmonary Disease Cancer Stroke Cholesterol Ulcers Depression Vascular Disease Diabetes Other Heart Disease   2. Do you take any prescription medication? Yes No If yes, please provide name of medication(s) and dosage. 3. Have any of your parents or siblings had heart disease of cancer prior to age 60? Yes No 4. Have you ever been rated, rejected or postponed for a life or disability policy? Yes No If yes, please provide details. 4. Coverage Desired Your maximum monthly benefit is approximately 60% of your monthly income. See Needs Calculator. Monthly Benefit Desired? Waiting Period Desired (days) 30 60 90 180 Benefit Period Desired 2 yrs 5 yrs Age 65 5. Submit Application How did you find us? -- Please Select -- Alta Vista AOL Ask Jeeves Google MSN Yahoo Forbes Other   If other:

Dennis P Stephens, CLU CA #0B65411 MN#20093118

1-800-TERM-USA

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