Chris A Roth

Disability Income Protection Assessment

Your ability to earn an income is your greatest financial asset. If an illness or injury stopped your paycheck, how long could you keep everything going?

Take 2–3 minutes to complete this assessment. Then we’ll review your situation and show you personalized disability income protection options that help keep your bills paid and your lifestyle on track.

First Name *

Last Name *

Date Of Birth

Phone *

Email *

State

Occupation

Aprox. Monthly Income

Current Disability Coverage

Anything else I should know about your situation?

What’s most important to you?

Best Time to Reach You

Consent to be contacted *

By checking this box and clicking “Submit My Disability Assessment Request”, you agree that Chris A. Roth and/or our partner carriers may contact you at the phone number and email address provided (including by autodialed, prerecorded, or artificial voice calls and text/SMS messages) about disability insurance, life insurance, and related products. You understand that your consent is not a condition of purchase and that you may revoke consent at any time. Message and data rates may apply. Your information is confidential and will only be used to provide your personalized recommendations.

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