Get a Quote for Insurance

Affincon is here to help your with all your insurance needs. Please complete the form below and an agent will contact you shortly to consult with your about the best disability insurance solution for your needs.

Disability Insurance Quote Form

Fields marked by an asterisk (*) are required fields.
 

Insured Information


Name*     Gender  
Date of Birth*
Address   Unit/Apt/Lot #  
City   State     Zip  
County
Email*
Home Phone   Work    Cell 
Preferred Contact Method*     Best Time to Call:* 
Average Monthly Income: 
What kind of work do you do?
 

Coverage Information


Why do you want to buy Disability Income Insurance?
 
Do you current have disability coverage?    If yes, please complete the information carrier information below.
Name of Carrier     Policy Number: 
Monthly Benefit
 
What Do You Like the Most About Your Current Coverage?
 
What Do You Like the Least About Your Current Coverage?
 

Required Medical Information


 
Height*  Feet     Inches
Weight*  lbs
Smoker*
Please describe any medical conditions:
List any Medications
being taken:

The protection of your privacy is important to us. Rest assured that the personal information you provide us with will not be disclosed to other parties and will be used solely for the purpose of bringing you the best service possible.
Life insurance

""I can recommend Ron Dutton, without reservation, as an expert in helping to find the best and most affordable insurance coverage available. Mr. Dutton helped me untangle the enormous mountain of information I received as I became eligible for Medicare. He listened carefully to my needs and concerns and used his exceptional expertise to advise me concerning my new coverage needs. Mr. Dutton is not only an expert in his field he is a man who can be trusted.""
Janet Love
Lawrenceville, GA