Palffy Insurance Group

Disability Income Insurance Quote Request

Disability-Income Quote Form
*Required Fields

First Name*

Last Name*

Phone Number*

Email Address*

Zip Code*

Annual Income*


Do you work at least 30 hours per week?*

Date of Birth*




Do you have a family physician?

When was your last check-up?

List any medical conditions for which you are currently being treated* (if you don't have any, type "none")

List any medical conditions that you recovered from in the last five years* (if you haven't had any, type "none")

List all medications you are currently taking and daily dosages* (if you don't take any, type "none")

Additional Comments:

A sales agent may call you as a result of submitting this form. We may need to clarify some information while completing your quote request. We may call you to discuss your options after you receive your quote.

The information you provide will only be used to satisfy your quote request. Certain information will be shared with insurance companies for quoting purposes only. No insurance company and no other insurance agency will market to you as a result of submitting this form. We do not share your information with outside organizations for marketing purposes.

Disability-Income Insurance

Disability-Income insurance provides periodic payments designed to help replace your income if you become disabled and are unable to work in your profession. Depending on the policy you choose, it can provide anywhere from 45% to 80% of your annual gross income on a tax-free basis.

Many people don’t plan for the possibility that they may face a debilitating illness or injury during their working years. It’s hard to imagine that something like this could happen. But when it does happen, it’s financially devastating.

The vast majority of Americans don’t have Disability-Income insurance. Some people have a Disability-Income policy through their employer, but these types of policies usually are pretty restrictive and don’t offer adequate coverage. If you have a policy through your employer, make sure you have an insurance agent review the coverage so that you know what you have.

There are a lot of things to consider when choosing a Disability-Income policy. Some policies cover short-term disabilities, some cover long-term disabilities, and some cover both. Most policies have a waiting period from the time you become disabled to the time the first payment is made. You can choose the waiting period that fits your situation best. Some policies cover accidental disability, some cover disabilities due to illness, and some cover both.

We can assist you with finding the right plan for your situation. We can also help you explore other income sources that may be available during a disability.