Howard Bersch Independent Insurance Broker

Learn more about insurance: Your coverage, deductable options & discounts available

Life

Dental

Health

A financially secure retirement that allows you to enjoy your new found free time doesn't just happen. It takes much thought and careful planning.

Disability Income Insurance Quote

To request a disability income insurance quote, please complete this form and click "submit" when you are finished.

Name:
State:
Zip Code:
Email Address:
Phone Number w/ Area Code:
Date of Birth:
Sex:	Male Female
Height:
Weight:
Your Salary:
Your Occupation:
Tobacco User:	No Yes Use smokeless tobacco Not now but smoked in last 12 months Not now but used smokeless in last 12 mo.
Current Disability Coverage, if any:
Your General State of Health:
Comments:

PLEASE NOTE THAT THE QUOTES YOU RECEIVE WILL BE BASED ON THE INFORMATION PROVIDED AND DOES NOT BIND THE INSURANCE COMPANY TO PROVIDE COVERAGE. ALL POLICIES ISSUED WILL BE BASED ON THE INSURANCE COMPANY'S UNDERWRITING REQUIREMENTS. A MEDICAL EXAMINATION AND/OR INFORMATION FROM YOUR PERSONAL PHYSICIAN MAY BE REQUIRED.