Disability Insurance

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Going without a paycheck isn’t an option for most people.  A sprained wrist, pregnancy or surgery may require time away from work without a paycheck.  Disability income insurance helps relieve the anxiety of not being able to earn a paycheck.  

At NEC Insurance Agency, Inc. We put the power of the internet to work for you! The following questions concern the type of business insurance coverage you are requesting . Please answer them as accurately as possible.

1) Business Name:

2) Description of the business:

3) What type of entity is your company?

4) Please indicate the state in which your business is located:

5) Please indicate your total # of full-time employees:

# of Part Time Employees:

6) Do you want the officers of the company to be included? YesNo

7) Please indicate your total annual revenue:

8) Please indicate your total annual payroll: Please enter amount: $

9) Do you currently have business auto insurance? YesNo

If you are currently insured, please select your current insurance carrier:

If your provider is not listed above, please provide the company name here:

10) How many years have you had coverage with this company?

11) How many years have you had continuous coverage (With no lapse)?

Business Information:

1) Business address:

Business address:

2) City:

3) State:

4) Zip Code:

The answer to these basic questions will help us process your information.

1) Best Time To Contact:

2) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

1. First Name:

2. Last Name:

3. Phone:

4. Email:

5. Address:

6. Address:

7. City:

8. State:

9. Zip Code:


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