NJ Employee Disability Insurance Quote

In addition to Group
Employee Disability
Insurance for your New
Jersey business, we also
offer affordable Employee
Health Insurance plan
premiums or choose
another NJ business
insurance coverage from
the list below.

**Information received from this New Jersey Employee Disability Insurance quote

request form sent to American Insurance Services Agency will be for our use only

and will not be sold, given to or distributed to any other parties. A quote will be based

on the employee disability insurance plan information provided and does not guarantee

acceptance of the risk by us. The precise coverage afforded is subject to meeting

underwriting guidelines, and the terms, conditions and exclusions of the policy as

issued. By submitting this request you acknowledge that this is neither an offer to

insure nor a guarantee of insurance. Completion of this form does not entitle you

to a New Jersey Employee Disability Insurance Plan Policy. We are licensed in New Jersey

and will not provide quotes for other states.

"Your Local New Jersey Employee Disability Insurance Agent!"

We offer affordable employee disability insurance plans to businesses in the

following New Jersey counties and cities: Union County, Essex County, Bergen

County, Passaic County, Sussex County, Morris County, Warren County,

Hunterdon County, Somerset County, Middlesex County, Monmouth County,

Mercer County, Burlington County, Clark, Newark, Jersey City, Elizabeth, Rahway,

Colonia, Iselin, Avenel, Woodbridge, Port Reading, Carteret, Perth Amboy, Fords,

South Amboy, Metuchen, Plainfield, Dunellen, South Plainfield, Green Brook,

Fanwood, North Plainfield, Cranford, Scotch Plains, Westfield, Union, Millburn,

Springfield, Mountainside, Gillette, Warren, Watchung, Stirling, Millington,

Middlesex, Martinsville, Piscataway, Edison, New Brunswick, Highland Park, North

Brunswick, Sayreville, East Brunswick, Somerset, Milltown, South River, Bound

Brook, Somerville, Bridgewater, Bayonne, Linden, Roselle, Hoboken, Union City,

Weehawken, West New York, Guttenberg, Cliffside Park, Edgewater, North Bergen,

Secaucus, Fairview, Ridgefield, Fort Lee, Leonia, Palisades Park, Englewood Cliffs,

Englewood, Bergenfield, Teaneck, Paramus, Bogota, Ridgefield Park, Little Ferry,

Hackensack, Maywood, Teterboro, South Hackensack, Rochelle Park, Moonache,

Lodi, Hasbrouck Heights, Saddle Brook, Garfield, Elmwood Park, Woodridge,

Carlstadt, East Rutherford, Lyndhurst, Rutherford, Wallington, Passaic, Clifton,

Paterson, Totowa, West Paterson, Little Falls, Great Notch, North Caldwell, Cedar

Grove, Verona, Montclair, Bloomfield, West Orange, Glen Ridge, Belleville, Nutley,

Kingsland, North Arlington, Kearney, Harrison, East Orange, East Newark, Orange,

Irvington, South Orange, Hillside, Townley, Livingston, Wayne, Trenton, Camden,

Atlantic City, Princeton, Vineland, Willingboro, and Toms River, NJ.

Group Disability Insurance Coverage Information:

Business Information:

Business Name:
Premises Address:
City:     State:     Zip Code:
Contact Name:
Phone #:    Ext #:    Years in Business:
Email Address: (Required)
Description of Operations or SIC code:

Current Insurance Company:
Policy Expiration Date:          (mm/dd/yyyy)

Do you currently offer short term disability insurance to employees?
Do you currently offer long term disability insurance to employees?
Length of Group Disability Coverage Needed?

Group Disability Coverage For?
Type of Group Disability Coverage Needed?
How many employees to be insured?

Monthly Benefit Amount For Each Person Insured: $
Or Enter a Different Monthly Benefit Amount:         $
Benefit Period Desired For Each Person Insured:
Elimination Period Desired For Each Person Insured:
Payment Mode:

Does any employee to be insured have a hazardous job? Yes No
If Yes, how many have hazardous jobs?

Are any employees to be insured active members of the military reserves? Yes No
If Yes, how many are active members of the military reserves?

Explain Any Recent Workers Compensation Claims Below.

Additional Information

Click on the "Submit Quote Information" button below to send your
New Jersey Group Disability insurance quote request.**