Thank you for your interest! Please provide a little information so we can help you. Which plan are you interested in?(Required) Short Term Disability Life Insurance Both Who are you wanting to cover with the life insurance?(Required) Myself Spouse Children Under 26 Employee Age:(Required)2526272829303132333435363738394041424344454647484950515253545556575859606162636465Employee Smokes?(Required) Yes No Spouse Age:(Required) Dependent Children Ages (Under 26):(Required) Waiting PeriodSelect14 Day Waiting Period30 Day Waiting PeriodMonthly Benefit (14-Day Wait)Select$1,500 Benefit/Month cost per day period = $57.32$1.600 Benefit/Month cost per day period = $61.00$1.700 Benefit/Month cost per day period = $64.69$1,800 Benefit/Month cost per day period = $68.38$1,900 Benefit/Month cost per day period = $72.07$2,000 Benefit/Month cost per day period = $75.75$2,100 Benefit/Month cost per day period = $79.44$2,200 Benefit/Month cost per day period = $83.13$2,300 Benefit/Month cost per day period = $86.82$2,400 Benefit/Month cost per day period = $90.50$2,500 Benefit/Month cost per day period = $94.19$2.600 Benefit/Month cost per day period = $97.88$2.700 Benefit/Month cost per day period = $101.56$2.800 Benefit/Month cost per day period = $105.25$2,900 Benefit/Month cost per day period = $108.95$3,000 Benefit/Month cost per day period = $112.63Monthly Benefit (30-Day Wait)Select$1,500 Benefit/Month cost per day period = $45.55$1.600 Benefit/Month cost per day period = $48.45$1.700 Benefit/Month cost per day period = $51.35$1,800 Benefit/Month cost per day period = $53.26$1,900 Benefit/Month cost per day period = $57.16$2,000 Benefit/Month cost per day period = $60.06$2,100 Benefit/Month cost per day period = $63.06$2,200 Benefit/Month cost per day period = $65.97$2,300 Benefit/Month cost per day period = $68.88$2,400 Benefit/Month cost per day period = $71.78$2,500 Benefit/Month cost per day period = $74.69$2.600 Benefit/Month cost per day period = $77.48$2.700 Benefit/Month cost per day period = $80.38$2.800 Benefit/Month cost per day period = $83.28$2,900 Benefit/Month cost per day period = $86.18$3,000 Benefit/Month cost per day period = $89.09Are you actively at work for the last 30 days?(Required) Yes No Name(Required) First Last Phone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Part time employee?(Required) Yes No Job Title(Required)SelectRural CarrierCity CarrierMail HandlerPSE ClerkRural Carrier AssociateSupervisorPostmasterClerkMaintenanceTractor Trailer DriverCustodianOtherMay we Text you to set up a time to talk by phone?(Required) Yes No Best day in the week to reach you?(Required)SundayMondayTuesdayWednesdayThursdayFridaySaturdayWhat time?(Required)MorningAfternoonEveningCAPTCHA
