Brian Wetzel

Disability & Life Quote

Please complete the following information if you would like to obtain a disability insurance quote. You may also call us toll-free at 866.494.1275.

Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. All information provided is strictly confidential and will be used solely for the purpose of developing a quote for you. As the sole owner of the information collected on this site, The Brian L. Wetzel Agency will not sell, share or rent this information to third parties for any reason whatsoever.

First Name:*
Last Name:*
DOB:* / /
Home Phone:*
Work Phone:*
Cell Phone:
Best contact place/time:*
Annual Income:*
Do you use tobacco?*
Current Disability Insurance:*
Current monthly Disability Insurance:
Would you like a life insurance quote:
If yes, what amount?
How did you hear about us?
Please list all health conditions requiring medical attention in the previous ten years:
Additional Comments: