Florida Group Disability Insurance Quote

Business Name:
Premises Address:
City: Florida      Zip Code:
Contact Name:
Phone #:    Ext #:    Years in Business:
Email Address: (Required)
Description of Operations or SIC code:

Current Insurance Company:
Policy Expiration Date:          (mm/dd/yyyy)

Do you currently offer short term disability insurance to employees?
Do you currently offer long term disability insurance to employees?
Length of Disability Coverage Needed?

Disability Coverage For?
Type of Disability Coverage Needed?
How many employees to be insured?

Monthly Benefit Amount For Each Person Insured: $
Or Enter a Different Monthly Benefit Amount:         $
Benefit Period Desired For Each Person Insured:
Elimination Period Desired For Each Person Insured:
Payment Mode:

Does any employee to be insured have a hazardous job? Yes No
If Yes, how many have hazardous jobs?

Are any employees to be insured active members of the military reserves? Yes No
If Yes, how many are active members of the military reserves?

Explain Any Recent Workers Compensation Claims Below.

Additional Comments or Questions

Click on the "Submit Quote Information" button below to send
your Florida Group Disability Insurance quote request.

We provide affordable group disability insurance quotes to the following south
Florida counties and cities: Miami-Dade County, Broward County, Palm Beach
County, Coral Gables, Kendall, Richmond Heights, Pinecrest, Howard, Coral
Way Village, Westchester, Westwood Lakes, Brownsville, Sweetwater, Key
Biscayne, North Bay Village, Miami Beach, Miami Springs, Virginia Gardens,
Hialeah, El Portal, Miami Shores, Indian Creek, Surfside, Bal Harbour, North
Miami, Biscayne Park, Pinewood Park, Opa Locka, Bunche Park, Hialeah
Gardens, Palm Springs North, Carol City, Miami, Norland, Ojus, Miami Lakes,
Biscayne Gardens, Hallandale, Sunny Isles Beach, Golden Beach, Aventura,
Uleta, Miramar, Pembroke Pines, North Miami Beach, Hallandale Beach, Ives
Estates, Pembroke Park, Hollywood, Dania Beach, Cooper City, Davie, Weston,
Plantation, Playland Isles, Melrose Park, Lauderhill, Sunrise, Tamarac, Fort
Lauderdale, Wilton Manors, Oakland Park, Lauderdale Lakes, Sea Ranch Lakes,
Pompano Beach, Margate, Coral Springs, North Lauderdale, Lighthouse Point,
Hillsboro Beach, Coconut Creek, Deerfield Beach, Boca Raton, The Hamptons,
Highland Beach, Boca West, Delray Beach, Boca Pointe, Boynton Beach,
Lantana, Rainbow Lakes, Atlantis, Lake Worth, South Palm Beach, Palm
Springs, Greenacres, Wellington, Haverhill, Palm Beach, Golden Lakes, Riviera
Beach, Glen Ridge, West Palm Beach, Lake Park, Royal Palm Beach, Jupiter,
Juno Beach, North Palm Beach, Loxahatchee, Belle Glade, Palm Beach Shores,
South Miami, Cutler Ridge, Princeton, Perrine, Naranja, Homestead, Florida City,
Leisure City, Key Largo, Tavernier, Islamorada, Key Colony Beach, Marathon,
Big Pine, Summerland Key, and Key West, FL

Information received from this south Florida group disability insurance quote form sent to
Insurance Benefit Agency will be for our use only and will not be sold, given to or distributed to
any other parties. A quote will be based on the group disability insurance information provided
and does not guarantee acceptance of the risk by us. The precise coverage afforded is subject to
meeting underwriting guidelines, and the terms, conditions and exclusions of the policy as
issued. By submitting this request you acknowledge that this is neither an offer to insure nor
a guarantee of insurance. Completion of this form does not entitle you to Florida group
disability insurance. We are licensed in Florida only and will not provide quotes for other states.