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With LeadExchange™ working for you, you'll have confidence that the leads that your web site produces are only from interested consumers.  Below you'll find a sample Disability Insurance lead.  All consumers are required to fill out a standardized questionnaire in order to be considered a valid lead.  To return, please click here

Why should you take out disability income protection insurance?

To guarantee income continuity in the event of sickness or accident.

To avoid a company having to fund the continuing salary for a disabled employee longer than may be otherwise desirable.

To pay the expenses of the business which would continue to be payable in the event of a principal owners disability

Instructions:  Please fill in this form as completely as possible in order to ensure that your quote will be as accurate as possible.

First Name


Last Name


Street Address






Zip Code


Day Phone


Evening Phone


E-mail Address


Best time to call:


Who is this quote for?




Birthday (mm/dd/yy)



 feet inches



Are you Self - Employed?


If ``No", who is your employer?


What type of business are you employed with?


What is your position?


How many years have you been with your current employer?


Occupation (IMPORTANT be as specific as possible)


Present Monthly Gross Income:


Monthly Benefit Requested: (What you will be paid monthly if disabled)


Please indicate tobacco use:


Do you participate in any hazardous activities?


Waiting Period: (time between injury and pay-out)


Benefit Period:


Please describe your
particular health problems:
(leave blank if none)


Please list any medications
and dosage
(leave blank if none)


Describe your family's history
of cancer and/or heart disease
(leave blank if none)


Would you like an additional quote for any of the following insurance products?

 Life Insurance
 Annuities (Retirement Vehicle)
 Long Term Care Insurance
 Health Insurance
 Group Health Insurance
 Auto Insurance
 Homeowners Insurance
 Home Loans