Group Short Term Disability

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Group Short Term Disability
Firstname *
Lastname *
In today's workplace, employers cannot ignore the need to provide workers with the opportunity to purchase short term disability coverage. The facts speak for themselves:
  • Every minute, 52 Americans become disabled.
  • In 1990 alone, over billion of income was lost to short term illness or injury.
  • And the incidence of disability is expected to increase 37 percent by the turn of the century.
  • These figures vividly point out the necessity for sound disability insurance protection.
  • With this in mind, please complete the below in order to provide through your employer, a group voluntary short term disability program for their employees (Note: Group must have the greater of 20 Employees or 25% participation.)
Policyholder Name
Occupation
Current Employer
Street Address
City *
State *
ZIP Code *
E-Mail *
Phone *
Fax

# Employees To Be Quoted *

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