Applicant Information

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Last Name:

Address:

City:

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Daytime Phone:

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How Best To Contact You:


Currently Insured:



Disability Insurance Information

Date of Birth:

Gender:

Height:

Weight:


Do You Smoke:


Currently Own Disability Insurance:


Type of Disability Insurance Owned:


Monthly Gross Income:
$

Occupation or Title:


Explain Job Responsibilities:


Are you a government employee:


Are you a business owner:




Disability Coverage Information

Length of Coverage Needed:


Disability Coverage For:


Type of Coverage Needed:


Monthly Benefit Amount Desired:


Or Enter a Different Monthly Amount:
$

Benefit Period:


Elimination Period:


Payment Mode:



Explain any prior workers comp
or serious health issues below:




Question or Message:




Click the "Submit Quote Request"
button below to send your New York
Disability Insurance request to
Direct Access Group Benefits.


***By submitting this request you
acknowledge that this is neither
an offer to insure nor a guarantee
of insurance.***








We are a Somers, NY insurance
agency offering affordable New York
disability insurance quotes in the
following towns, cities and counties
in the Westchester County, NY area:
Port Chester, Harrison, Mamaroneck,
Larchmont, New Rochelle, Yonkers,
White Plains, Rye Brook, Scarsdale,
Rye, Ardsley, Hartsdale, Bronxville,
Mount Vernon, Irvington, Valhalla,
Elmsford, Dobbs Ferry, Hastings
on Hudson, Greenburgh, Tarrytown,
Sleepy Hollow, Hawthorne,
Scarborough, Thornwood, Briarcliff
Manor, Ossining, Harmon, Montrose
Crugers, Buchanan, Peekskill, Millwood,
Pleasantville Armonk, Chappaqua, North
Castle, Mt. Kisco, Bedford, Pound Ridge,
Bedford Hills, Cross River, South Salem,
Yorktown Heights, Goldens Bridge,
Amawalk, Yorktown, Katonah, Salem
Center, Somers, North Salem, Croton
Falls, Jefferson Valley, Shrub Oak,
Palisades, Sparkill, Tappan, Orangeburg,
Pearl River, West Nyack, New City,
Nanuet, Chestnut Ridge, Montebello,
Suffern, Monsey, Spring Valley, Congers,
Nyack, Rockland Lake, Wesley Hills,
New Hempstead, Pomona, Sloatsburg,
Ramapo, Hilburn, Willow Grove, Mt. Ivy,
Thiells, Tomkins Cove, Ladentown,
Haverstraw, Stony Point, Tomkins Cove,
West Haverstraw, Bear Mountain, Jones
Point, Newburgh, Middletown, Bronx,
New York City, Brewster, Poughkeepsie,
Putnam County, Orange County, and
Rockland County, New York.
Disability Insurance Quote
Direct Access Group Benefits, Inc.
© 2004, All Rights Reserved
914-276-6000
800-498-1819
Westchester County New York Insurance Agency