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Request for Proposal

  1. Personal Info
  2. Employment Info
  3. Existing Coverage
  4. Medical History
Personal Information
Questions? Contact a Fortify sales agent
phone: (203) 226-4077, email: illustrations@fortifyinsurance.com

Gender
Premium rates are partly based on gender.
Note: Female rates are higher than male rates so be sure to list the name of your Employer to see if special discounting may be available!

Male Female

First Name
We don't really need to know your name ... but it is nice.
Please know that your personal information is sacred to us and will not be shared with anyone without your permission

Last Name

Birthday
Premiums rates are partly based on your age.
Most disability insurance carriers calculate premiums based on "actual age" while many Life Insurance carriers calculate premiums based on "nearest age"

State of Residence
Premiums are also based on your state of residence.

Check here if you would like your quote texted to you

*We will not call you or share your contact information with anyone unless you give us permission to do so.

Employment Information
Questions? Contact a Fortify sales agent
phone: (203) 226-4077, email: illustrations@fortifyinsurance.com

Name of Employer
Fortify has access to many special Discount Programs.
Note: very often we can offer special discounts based on Employer, Residency/Fellowship Program, Hospital, or Association.

Base Salary
Why do we ask this?
Disability Income Insurance maximum benefits are based off of income.

Bonus Income

Business Owner
As a Business Owner you may be eligible for policy upgrades based on the information provided.
Note: This is a great way to save money on this valuable protection!

No Yes
Number of Years
Number of Employees

Occupation
In addition to state of residence and age, premiums are also based on your current occupation.

Do you work at least 30hrs/week?
Most Disability Income policies require that you are working at least 30 hours per week but Fortify also has options for those working on a part-time basis

Yes No
Number of Hours:
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Existing Coverage
Questions? Contact a Fortify sales agent
phone: (203) 226-4077, email: illustrations@fortifyinsurance.com

Do you have any inforce Disability Insurance Coverage?

No Yes

Group LTD through Employer?

No Yes

Who Pays the premiums?

Employer Me

What are the coverage parameters?

Percent of income replacement to maximum benefit of

Individual / Association Coverage?

No Yes

Name of Insurer (if known)

What are the coverage parameters?

Monthly benefit amount

Elimination Period

Benefit Period

Additional Individual Policies?

No Yes

Name of Insurer (if known)

What are the coverage parameters?

Monthly benefit amount

Elimination Period

Benefit Period

Medical History
Questions? Contact a Fortify sales agent
phone: (203) 226-4077, email: illustrations@fortifyinsurance.com

Height
Height and weight can be a factor in the rate as Insurance carriers believe elevated weight can increase the risk of future disability.

Normal

Weight
Height and weight can be a factor in the rate as Insurance carriers believe elevated weight can increase the risk of future disability.

Normal

Do you smoke?

No Yes
Type

Notable Medical History or Other Information

Please include current prescriptions, previous surgery, recent symptoms treated by a physician, etc...

*All information you provide Fortify Insurance Group is kept confidential and ONLY used for the purposes of securing an accurate proposal.

SUCCESS!
Questions? Contact a Fortify sales agent
phone: (203) 226-4077, email: illustrations@fortifyinsurance.com

Your request has been received by Fortify Insurance Group and our Illustrations team will begin processing right away.

Generally quotes are processed within 24 hours from receipt but if there is specific medical or other case details that require special underwriting consideration the turnaround could take a longer.

If additional information is needed a Brokerage Consultant will get in touch with you and you can check status of your request by calling 203-226-4077 or emailing illustrations@fortifyinsurance.com

Thanks for your support and we look forward to assisting you.


- Your friends at Fortify Insurance Group.

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Request for Proposal

Welcome to the Fortify Insurance Group Request for Proposal tool.

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