www.disabilityquotes.com
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urlscan Pro
3.227.100.80
Public Scan
Submitted URL: http://www.disabilityquotes.com/jy
Effective URL: https://www.disabilityquotes.com/JY
Submission: On November 08 via manual from US — Scanned from DE
Effective URL: https://www.disabilityquotes.com/JY
Submission: On November 08 via manual from US — Scanned from DE
Form analysis 2 forms found in the DOM
GET /site-search
<form method="get" accept-charset="utf-8" id="mobile-search" class="clearfix" action="/site-search"> <input placeholder="Search our site" name="q">
<button type="submit">
<i class="fa fa-search" aria-hidden="true"></i>
</button>
</form>POST /applications/e-apps/insured-info?eId=177237&eUuid=21bef288-3729-4e54-8d8a-c034ca325ef0
<form method="post" enctype="multipart/form-data" accept-charset="utf-8" novalidate="novalidate" id="create-e-app" autocomplete="off" action="/applications/e-apps/insured-info?eId=177237&eUuid=21bef288-3729-4e54-8d8a-c034ca325ef0">
<div style="display:none;"><span class="before-block"></span>
<input name="_csrfToken" type="hidden" autocomplete="off" value="c275d9f2e202af6c38d1da0fe0136e5bbbacf408b715382b6d945e19" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
<div class="row">
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="first-name">First Name <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="first_name" type="text" maxlength="255" required="required" data-validity-message="First Name is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="first-name" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="last-name">Last Name <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="last_name" type="text" maxlength="255" required="required" data-validity-message="Last Name is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="last-name" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-form form-group text ">
<label class="label" for="previous-last-name">Previous Last Name <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="previous_last_name" type="text" maxlength="255" id="previous-last-name" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="ssn">Social Security Number <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="ssn" type="text" required="required" class="form-control us_ssn" data-validity-message="Social Security Number is required"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')" id="ssn" inputmode="text">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-4">
<div class="m-b-10 radio required form-group">
<label class="label">Gender <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="gender" type="hidden" value="" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
<label class="custom-control custom-radio"><input type="radio" name="gender" value="Male" class="custom-control-input" id="gender-male" required="required" data-validity-message="Select a gender"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label" for="gender-male">Male</label></label><label
class="custom-control custom-radio"><input type="radio" name="gender" value="Female" class="custom-control-input" id="gender-female" required="required" data-validity-message="Select a gender"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label" for="gender-female">Female</label></label>
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="md-form form-group text required">
<label class="label" for="street">Street Address <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="street" type="text" required="required" data-validity-message="Street Address is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="street" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="row">
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="city">City <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="city" type="text" required="required" data-validity-message="City is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"
id="city" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-padding select required">
<span class="before-block"></span>
<select name="state_abbr" id="select-state" required="required" class="select2 form-control select2-hidden-accessible" data-validity-message="State must be selected"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')" data-select2-id="select-state" tabindex="-1" aria-hidden="true">
<option value="" data-select2-id="2">State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="1" style="width: 376.656px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-disabled="false" aria-labelledby="select2-select-state-container"><span class="select2-selection__rendered" id="select2-select-state-container" role="textbox"
aria-readonly="true" title="State">State</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="zip-code">Zip <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="zip_code" type="text" required="required" data-validity-message="Zip Code is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="zip-code" maxlength="25" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="m-b-10 radio required form-group">
<label class="label">How long have you lived at this address? <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="current_address_more_two_years" type="hidden" value="" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
<label class="custom-control custom-radio"><input type="radio" name="current_address_more_two_years" value="0" class="custom-control-input" id="current-address-more-two-years-0" required="required"
data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label"
for="current-address-more-two-years-0">Less than two years</label></label><label class="custom-control custom-radio"><input type="radio" name="current_address_more_two_years" value="1" class="custom-control-input"
id="current-address-more-two-years-1" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')"><label class="custom-control-label" for="current-address-more-two-years-1">More than two years</label></label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="md-form form-group text required">
<label class="label" for="dob">Date Of Birth <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="dob" type="text" required="required" class="datepicker form-control hasDatepicker" data-validity-message="Date of Birth is required"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')" id="dob">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-6">
<div class="md-form form-group text required">
<label class="label" for="place-birth">Place Of Birth <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="place_birth" type="text" required="required" data-validity-message="Place of Birth is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="place-birth" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="md-form form-group text required">
<label class="label" for="email">Email Address <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="email" type="text" maxlength="255" required="required" data-validity-message="Email cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="email" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-6">
<div class="md-form form-group tel required">
<label class="label" for="phone">Phone Number <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="phone" type="tel" maxlength="255" required="required" data-validity-message="Phone is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="phone" class="form-control" inputmode="text">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="previous-address mt-5" style="display: none;">
<h4> Previous Address </h4>
<div class="row">
<div class="col-12">
<div class="md-form form-group text required">
<label class="label" for="previous-street">Previous Street Address <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="previous_street" type="text" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="previous-street" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="row">
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="previous-city">Previous City <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="previous_city" type="text" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="previous-city" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-padding select required">
<span class="before-block"></span>
<select name="previous_state_abbr" required="required" class="select2 form-control select2-hidden-accessible" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')" id="previous-state-abbr" data-select2-id="previous-state-abbr" tabindex="-1"
aria-hidden="true">
<option value="" data-select2-id="4">State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="3" style="width: 376.656px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-disabled="false" aria-labelledby="select2-previous-state-abbr-container"><span class="select2-selection__rendered" id="select2-previous-state-abbr-container" role="textbox"
aria-readonly="true" title="State">State</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="previous-zip-code">Previous Zip <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="previous_zip_code" type="text" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="previous-zip-code" maxlength="25" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="m-b-10 radio required form-group">
<label class="label">Are you a US Citizen or Green Card holder? <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="us_citizen" type="hidden" value="" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
<label class="custom-control custom-radio"><input type="radio" name="us_citizen" value="0" class="custom-control-input" id="us-citizen-0" required="required" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label" for="us-citizen-0">No</label></label><label
class="custom-control custom-radio"><input type="radio" name="us_citizen" value="1" class="custom-control-input" id="us-citizen-1" required="required" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label" for="us-citizen-1">Yes</label></label>
</div>
</div>
</div>
<div class="residence-continuous" style="display: none;">
<div class="row">
<div class="col-md-6">
<div class="md-padding select required">
<span class="before-block"></span>
<select name="visa_type" required="required" class="select2 md-padding select2-hidden-accessible" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')" id="visa-type" data-select2-id="visa-type" tabindex="-1" aria-hidden="true">
<option value="" data-select2-id="6">Visa Type</option>
<option value="A-1">A-1</option>
<option value="A-2">A-2</option>
<option value="A-3">A-3</option>
<option value="B-1">B-1</option>
<option value="B-2">B-2</option>
<option value="C-1">C-1</option>
<option value="C-1D">C-1D</option>
<option value="C-2">C-2</option>
<option value="C-3">C-3</option>
<option value="C-4">C-4</option>
<option value="D-1">D-1</option>
<option value="D-2">D-2</option>
<option value="E-1">E-1</option>
<option value="E-2">E-2</option>
<option value="Employment Authorization Document">Employment Authorization Document</option>
<option value="F-1">F-1</option>
<option value="F-2">F-2</option>
<option value="G-1">G-1</option>
<option value="G-2">G-2</option>
<option value="G-3">G-3</option>
<option value="G-4">G-4</option>
<option value="G-5">G-5</option>
<option value="Green Card (Permanent Visa)">Green Card (Permanent Visa)</option>
<option value="H-1B">H-1B</option>
<option value="H-1C">H-1C</option>
<option value="H-2A">H-2A</option>
<option value="H-2B">H-2B</option>
<option value="H-3">H-3</option>
<option value="H-4">H-4</option>
<option value="I">I</option>
<option value="J-1">J-1</option>
<option value="J-2">J-2</option>
<option value="K-1">K-1</option>
<option value="K-2">K-2</option>
<option value="K-3">K-3</option>
<option value="K-4">K-4</option>
<option value="L-1A">L-1A</option>
<option value="L-1B">L-1B</option>
<option value="L-2">L-2</option>
<option value="M-1">M-1</option>
<option value="M-2">M-2</option>
<option value="N-8">N-8</option>
<option value="N-9">N-9</option>
<option value="NAFTA">NAFTA</option>
<option value="NATO-1">NATO-1</option>
<option value="NATO-2">NATO-2</option>
<option value="NATO-3">NATO-3</option>
<option value="NATO-4">NATO-4</option>
<option value="NATO-5">NATO-5</option>
<option value="NATO-6">NATO-6</option>
<option value="NATO-7">NATO-7</option>
<option value="O-1">O-1</option>
<option value="O-2">O-2</option>
<option value="O-3">O-3</option>
<option value="P-1">P-1</option>
<option value="P-2">P-2</option>
<option value="P-3">P-3</option>
<option value="P-4">P-4</option>
<option value="Q-1">Q-1</option>
<option value="Q-2">Q-2</option>
<option value="Q-3">Q-3</option>
<option value="R-1">R-1</option>
<option value="R-2">R-2</option>
<option value="S-5">S-5</option>
<option value="S-6">S-6</option>
<option value="T">T</option>
<option value="T-1">T-1</option>
<option value="T-2">T-2</option>
<option value="T-3">T-3</option>
<option value="T-4">T-4</option>
<option value="TN">TN</option>
<option value="TD">TD</option>
<option value="TWOV">TWOV</option>
<option value="U">U</option>
<option value="U-1">U-1</option>
<option value="U-2">U-2</option>
<option value="U-3">U-3</option>
<option value="U-4">U-4</option>
<option value="V-1">V-1</option>
<option value="V-2">V-2</option>
<option value="V-3">V-3</option>
<option value="TPS">TPS</option>
<option value="other">other</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="5" style="width: 580px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-disabled="false" aria-labelledby="select2-visa-type-container"><span class="select2-selection__rendered" id="select2-visa-type-container" role="textbox" aria-readonly="true"
title="Visa Type">Visa Type</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="visa-type-other-explain col-md-6" style="display: none;">
<div class="col-md-12">
<div class="md-form form-group text required">
<label class="label" for="visa-type-explain">Please Explain: <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="visa_type_explain" type="text" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="visa-type-explain" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="col-md-6">
<div class="md-padding select required">
<span class="before-block"></span>
<select name="visa_duration" required="required" class="select2 md-padding select2-hidden-accessible" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')" id="visa-duration" data-select2-id="visa-duration" tabindex="-1" aria-hidden="true">
<option value="" data-select2-id="8">Visa Duration</option>
<option value="6 months">6 months</option>
<option value="1 year">1 year</option>
<option value="1.5 years">1.5 years</option>
<option value="2 years">2 years</option>
<option value="2.5 years">2.5 years</option>
<option value="3 years">3 years</option>
<option value="3.5 years">3.5 years</option>
<option value="4 years">4 years</option>
<option value="4.5 years">4.5 years</option>
<option value="5 years">5 years</option>
<option value="5.5 years">5.5 years</option>
<option value="6 years">6 years</option>
<option value="6.5 years">6.5 years</option>
<option value="7 years">7 years</option>
<option value="7.5 years">7.5 years</option>
<option value="8 years">8 years</option>
<option value="8.5 years">8.5 years</option>
<option value="9 years">9 years</option>
<option value="9.5 years">9.5 years</option>
<option value="10 years">10 years</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="7" style="width: 580px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-disabled="false" aria-labelledby="select2-visa-duration-container"><span class="select2-selection__rendered" id="select2-visa-duration-container" role="textbox"
aria-readonly="true" title="Visa Duration">Visa Duration</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper"
aria-hidden="true"></span></span>
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="m-b-10 radio required form-group">
<label class="label">Has your residence in the U.S. been continuous? <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="continuous_residence" type="hidden" value="" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
<label class="custom-control custom-radio"><input type="radio" name="continuous_residence" value="0" class="custom-control-input" id="continuous-residence-0" required="required" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label" for="continuous-residence-0">No</label></label><label
class="custom-control custom-radio"><input type="radio" name="continuous_residence" value="1" class="custom-control-input" id="continuous-residence-1" required="required" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label" for="continuous-residence-1">Yes</label></label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="m-b-10 radio required form-group">
<label class="label">Do you expect to remain in the U.S. permanently? <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="us_permanently" type="hidden" value="" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
<label class="custom-control custom-radio"><input type="radio" name="us_permanently" value="0" class="custom-control-input" id="us-permanently-0" required="required" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label" for="us-permanently-0">No</label></label><label
class="custom-control custom-radio"><input type="radio" name="us_permanently" value="1" class="custom-control-input" id="us-permanently-1" required="required" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label" for="us-permanently-1">Yes</label></label>
</div>
</div>
</div>
<div class="residence-permanently" style="display: none;">
<div class="row">
<div class="col-12">
<div class="md-form form-group text required">
<label class="label" for="permanently-details">Please provide details <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="permanently_details" type="text" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="permanently-details" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="m-b-10 radio required form-group">
<label class="label">Do you plan to reside in another country besides the US in the next 2 years? <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="reside_on_another_country" type="hidden" value="" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
<label class="custom-control custom-radio"><input type="radio" name="reside_on_another_country" value="0" class="custom-control-input" id="reside-on-another-country-0" required="required"
data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label
class="custom-control-label" for="reside-on-another-country-0">No</label></label><label class="custom-control custom-radio"><input type="radio" name="reside_on_another_country" value="1" class="custom-control-input"
id="reside-on-another-country-1" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')"><label class="custom-control-label" for="reside-on-another-country-1">Yes</label></label>
</div>
</div>
</div>
<div class="reside-another-country" style="display: none;">
<div class="row">
<div class="col-12">
<div class="md-form form-group text required">
<label class="label" for="reside-on-another-country-details">Please include details <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="reside_on_another_country_details" type="text" required="required" data-validity-message="This field cannot be left empty"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')" id="reside-on-another-country-details" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="md-form form-group text required">
<label class="label" for="obtain-permanent-residency">When do you expect to obtain US citizenship or permanent residency (green Card)? Provide Details <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="obtain_permanent_residency" type="text" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="obtain-permanent-residency" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="md-form form-group text required">
<label class="label" for="employer-name">Employer Name <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="employer_name" type="text" maxlength="255" required="required" data-validity-message="Employer Name is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="employer-name" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="m-b-10 radio required form-group">
<label class="label">Number of years with current employer <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="current_employer_more_two_years" type="hidden" value="" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
<label class="custom-control custom-radio"><input type="radio" name="current_employer_more_two_years" value="0" class="custom-control-input" id="current-employer-more-two-years-0" required="required"
data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')"><label class="custom-control-label"
for="current-employer-more-two-years-0">Less than two years</label></label><label class="custom-control custom-radio"><input type="radio" name="current_employer_more_two_years" value="1" class="custom-control-input"
id="current-employer-more-two-years-1" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')"><label class="custom-control-label" for="current-employer-more-two-years-1">More than two years</label></label>
</div>
</div>
</div>
<div class="current-employer-name" style="display: none;">
<div class="row">
<div class="col-md-6">
<div class="md-form form-group text required">
<label class="label" for="months-current-employer">Months with current employer <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="months_current_employer" type="text" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="months-current-employer" maxlength="10" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-6">
<div class="md-form form-group text required">
<label class="label" for="previous-employer-name">Previous employer name <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="previous_employer_name" type="text" required="required" data-validity-message="This field cannot be left empty" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="previous-employer-name" maxlength="120" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="md-form form-group text required">
<label class="label" for="current-business">Nature of current Business <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="current_business" type="text" required="required" data-validity-message="Nature of current business is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="current-business" maxlength="150" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="current-employer-address mt-5">
<h4> Current Employer Address </h4>
<div class="row">
<div class="col-12">
<div class="md-form form-group text required">
<label class="label" for="employer-street">Street Address <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="employer_street" type="text" required="required" data-validity-message="Street Address is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="employer-street" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div class="row">
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="employer-city">City <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="employer_city" type="text" required="required" data-validity-message="City is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="employer-city" maxlength="100" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-padding select required">
<span class="before-block"></span>
<select name="employer_state_abbr" required="required" class="select2 md-padding select2-hidden-accessible" data-validity-message="State must be selected"
oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)" oninput="this.setCustomValidity('')" id="employer-state-abbr" data-select2-id="employer-state-abbr" tabindex="-1"
aria-hidden="true">
<option value="" data-select2-id="10">State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="9" style="width: 376.656px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-disabled="false" aria-labelledby="select2-employer-state-abbr-container"><span class="select2-selection__rendered" id="select2-employer-state-abbr-container" role="textbox"
aria-readonly="true" title="State">State</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
<div class="col-md-4">
<div class="md-form form-group text required">
<label class="label" for="employer-zip-code">Zip <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="employer_zip_code" type="text" required="required" data-validity-message="Zip Code is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="employer-zip-code" maxlength="25" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="md-form form-group text required">
<label class="label" for="employees-count">Approximately how many people are employed by your current business/organization? <span class="content-after-label-text"></span>
<span class="tooltip-effect-5 akf-tooltip mytooltip"></span>
</label>
<span class="before-block"></span>
<input name="employees_count" type="text" required="required" data-validity-message="Answer is required" oninvalid="this.setCustomValidity(''); if (!this.value) this.setCustomValidity(this.dataset.validityMessage)"
oninput="this.setCustomValidity('')" id="employees-count" maxlength="11" class="form-control">
<span class="after-block"></span>
<span class="help-block"></span>
</div>
</div>
</div>
<div id="ca-fraud-statement" class="mt-4" style="display: none;">
<h4>Fraud Statement</h4>
<p> Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. </p>
</div>
<div class="form-group submit ">
<input type="submit" class="btn btn-secondary btn-continue" value="Continue">
</div>
</form>Text Content
Drs Choices Insurance Services, Inc. Your Agent : Judith YounessianJ. Younessian * By Profession By Profession AttorneyBusiness OwnersDentistsDoctorsExecutivesIT IndustryProfessionalsSalesOther * Learn Learn FAQStatisticsArticles * About Us About Us Our TeamContact Us * For Agents For Agents Agent RegistrationProductsDI Quote Calculator Login Login Get a Quote PRE-APPLICATION QUESTIONNAIRE 0% THE PURPOSE OF THIS FORM IS SIMPLY TO GATHER INFORMATION TO HELP COMPLETE AN APPLICATION FOR DISABILITY OR LIFE INSURANCE - IT IS NOT AN APPLICATION. IF YOU APPLY FOR INSURANCE YOU MAY BE ASKED ADDITIONAL OR DIFFERENT QUESTIONS. ONCE YOU HAVE COMPLETED THIS FORM, YOUR AGENT WILL USE THE INFORMATION REQUESTED IN THIS PRE-APPLICATION QUESTIONNAIRE TO HELP PREPARE YOUR FORMAL E-APPLICATION, WHICH REQUIRES YOUR REVIEW AND AUTHORIZATION BEFORE BEING SUBMITTED TO THE INSURANCE COMPANY, A SEPARATE SECURE LINK WILL BE SENT TO YOU WHEN THIS PROCESS IS COMPLETE. YOUR AGENT MAY CONTACT YOU WITH QUESTIONS. * 1Insured Information * 2Occupation Information * 3Financial Information * 4Additional Information * 5Coverage & Health Info INSURED INFORMATION First Name Last Name Previous Last Name Social Security Number Gender MaleFemale Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip How long have you lived at this address? Less than two yearsMore than two years Date Of Birth Place Of Birth Email Address Phone Number PREVIOUS ADDRESS Previous Street Address Previous City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Previous Zip Are you a US Citizen or Green Card holder? NoYes Visa TypeA-1A-2A-3B-1B-2C-1C-1DC-2C-3C-4D-1D-2E-1E-2Employment Authorization DocumentF-1F-2G-1G-2G-3G-4G-5Green Card (Permanent Visa)H-1BH-1CH-2AH-2BH-3H-4IJ-1J-2K-1K-2K-3K-4L-1AL-1BL-2M-1M-2N-8N-9NAFTANATO-1NATO-2NATO-3NATO-4NATO-5NATO-6NATO-7O-1O-2O-3P-1P-2P-3P-4Q-1Q-2Q-3R-1R-2S-5S-6TT-1T-2T-3T-4TNTDTWOVUU-1U-2U-3U-4V-1V-2V-3TPSother Visa Type Please Explain: Visa Duration6 months1 year1.5 years2 years2.5 years3 years3.5 years4 years4.5 years5 years5.5 years6 years6.5 years7 years7.5 years8 years8.5 years9 years9.5 years10 years Visa Duration Has your residence in the U.S. been continuous? NoYes Do you expect to remain in the U.S. permanently? NoYes Please provide details Do you plan to reside in another country besides the US in the next 2 years? NoYes Please include details When do you expect to obtain US citizenship or permanent residency (green Card)? Provide Details Employer Name Number of years with current employer Less than two yearsMore than two years Months with current employer Previous employer name Nature of current Business CURRENT EMPLOYER ADDRESS Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Approximately how many people are employed by your current business/organization? FRAUD STATEMENT Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Judith Younessian (310) 525-6900 Email me We value your privacy. Due to the confidential nature of the questions being asked, we limit the amount of time that we maintain your information. Once you complete the questionnaire, your answers are delivered securely to your agent, who will complete your official application and send to you securely for your review and signature. Please call your agent, Judith Younessian at (310) 525-6900 with any questions. Thank you for working with us on your coverage. Certified Financial Services is an independent agency authorized to offer products of The Guardian Life Insurance Company of America (Guardian), New York, NY and its subsidiaries, and is not an affiliate or subsidiary of Guardian. The Guardian Logo is a registered service mark of Guardian, used with permission. 2021-124389 (Exp. 8/24) Disability Insurance Quotes 9200 Corporate Boulevard, Suite 390 / Rockville, MD 20850 888-513-2300 Financial Balance Group LLC is a general agency of The Guardian Life Insurance Company of America, NY, NY. Disability Insurance Quotes is the brokerage arm of Financial Balance Group LLC. Agent information provided on this web site is for broker use only. For important information about the products and insurers discussed on this page, as well as information concerning Disability Insurance Quotes or the General Agency representing Guardian, please click here. Copyright Steven L. Crawford (General Agent). We take protecting your data and privacy very seriously. As of January 1, 2020 the California Consumer Privacy Act (CCPA) suggests the following link as an extra measure to safeguard your data: Do not sell my personal information. * Site Map * Contact Us * Privacy Notice * Disclaimer * Terms of Use