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Disability Insurance Quote Request

Please complete the following secure form to get your free, no-obligation quote for disability income protection. If you have any questions as you’re filling out the form, please feel free to call Wescom Insurance Services at 1-888-4WESCOM (1-888-493-7266), ext. 1080, Monday through Friday from 8:30 a.m. to 5 p.m. PST.

This is not an application for insurance. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Your Information

First Name:
Last Name:
Date of Birth:
Home Phone:
Work Phone:
Best time to call:
List all medications and reason for them
Do you smoke or use tobacco?
Do you participate in any hazardous sports or activities (such as scuba diving, any racing, mountain climbing, hang gliding and skydiving)?
Known medical condition or history?
What is your profession?
How long in this occupation?
If you have a specialty, what is it?
If you hold professional designation(s) or degree(s), what are they?
Annual Income: Gross earned income before taxes, but after business expenses? Current Year    
Last Tax Year   
Do you have existing income coverage? Is so, please explain.
Is there information we should know that will help us give you an accurate quote?
Will the premium be paid by you personally (that is, after taxes) or by your employer (before taxes)?
How did you hear about Wescom?
Additional Information: