Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

Note: If you do not hear back from us within 24 hours, please call 800-955-0040.
Ask for Lisa or Kirk. Thank you!

*We respect your right to personal privacy. To that end, we collect and use the information you provide to us for quoting purposes only. The information we collect is never shared with other organizations and/or for commercial purposes. If you have
any questions or concerns regarding this statement, please contact Kirk by email at: kwoolsey@dwassociates.com.

Disability Insurance Pre-Screening Questionnaire--For Broker Use Only

Broker Name

Broker Phone


Prospect Information

First Name Last Name


Residence State:

Work State:

Gender M F

Tobacco Use yes no




Years in current position:

Annual Net Income:

Current year: Prior Year:


Current year: Prior Year:

Self Employed or Business Owner? Number of years?

How many employees?

Work from home office? yes % of time at home office:

Existing Group DI Benefits Existing Individual DI Benefits

Medical History: (Neck, Back, Mental/Nervous, Blood Pressure etc.)


Height: Weight:

Coverage Type:

Individual Overhead Expense Buy Out



Own Occupation


Own Occupation, not engaged

Non Can

Future Purchase Option

Catastrophic Illness

One-Stop Source: Disability Partner gives you a one-stop point of contact for all of your clients' DI needs. You have access to the leading DI carriers, superior service, and the best support and experience in the industry.

Superior Presentations: The best carriers and seasoned experts insure your presentations are competitive and fit your client's needs.

Service You Can Count On: From your first call to us -- to your everyday needs -- you'll discover a level of service that supports your success. Sales, underwriting and administrative professionals are here to customize a DI plan for your client needs and provide the full support you need.

Full Support: When you need help with a point of sale, want a training seminar for your agency, or have a simple question, we can help. Disability Partner is your individual disability insurance expert.

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