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  Information Request — Individual

 

Thank you for your interest in Unum's disability insurance for individuals. Please complete the following information so that an agent can contact you regarding your request within 24 hours (M-F), or call our Sales Support Center at 877-322-7222. All information entered will be for Unum use only and will remain confidential (view our Privacy Statement).

[Unum does not offer short term disability (STD) insurance or life insurance to individuals except through their employers. If you are interested in STD or life insurance, please check with your employer to learn what benefits may be available to you.]

* Indicates required field
Name: *  
E-mail Address: *   
City: *
State: *  
Zip Code: *   
Date of Birth: *  
Occupation: *  
Self-Employed: *   
Years In Occupation or Self-Employed: *  
Annual Income: *  
Any Other Disability Coverage: *  
Contact Me Via:  
What product(s) are you interested in? (select all that apply)

 

Disability insurance and individual long term care insurance require full medical underwriting. Serious medical conditions or build outside established height and weight tables may affect coverage availability. Please provide additional information below to make us aware of any medical conditions or build issues so we can suggest the most appropriate solutions.
 
Any known medical conditions?
 
Current Measurements: Height    Weight
 
Are you currently taking any medication?
 


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