{"formType":"disability-form","title":"Disability Insurance Proposal Request","description":"Request a disability insurance quote to protect your income. A few questions about your work, income and health; a licensed Susman agent compares short-term and long-term options.","estimatedMinutes":8,"wordpressUrl":"https://www.susmaninsurance.com/quotes/forms/disability-form/","engineUrl":"https://forms.susmaninsurance.com/?form=disability-form","nameRequired":false,"questionCount":23,"requiredCount":19,"questions":[{"name":"name","title":"Name","type":"text","required":true,"page":1},{"name":"how_did_you_find_us","title":"How did you find us?","type":"radiogroup","required":true,"page":2,"choices":["Search engines","Social media","News story","Referral","I am a current client of Susman Insurance"]},{"name":"name_of_referral","title":"Name of Referral","type":"text","required":true,"page":3,"visibleIf":"({how_did_you_find_us} = 'Referral')"},{"name":"phone","title":"Phone","type":"text","required":true,"page":4,"inputType":"tel"},{"name":"email","title":"Email","type":"text","required":true,"page":5,"inputType":"email"},{"name":"address__address","title":"Address","type":"text","required":true,"page":6,"section":"Address"},{"name":"address__addressline2","title":"Address line 2","type":"text","required":false,"page":6,"section":"Address"},{"name":"address__city","title":"City/Town","type":"text","required":true,"page":6,"section":"Address"},{"name":"address__state","title":"State/Region/Province","type":"text","required":true,"page":6,"section":"Address"},{"name":"address__zipcode","title":"Zip/Post Code","type":"text","required":true,"page":6,"section":"Address"},{"name":"address__country","title":"Country","type":"text","required":false,"page":6,"section":"Address"},{"name":"have_you_had_any_claims_in_the_last_5_years","title":"Have you had any claims in the last 5 years?","type":"radiogroup","required":true,"page":7,"choices":["Yes","No"]},{"name":"occupation","title":"Occupation","type":"text","required":true,"page":8},{"name":"last_year_s_approximate_gross_income","title":"Last year's approximate Gross income","type":"text","required":false,"page":9,"inputType":"number"},{"name":"name_of_current_employer","title":"Name of current employer?","type":"text","required":false,"page":10},{"name":"do_you_smoke_or_vape_tobacco","title":"Do you smoke or vape tobacco?","type":"radiogroup","required":true,"page":11,"choices":["Yes","No"]},{"name":"do_you_smoke_or_vape_marijuana","title":"Do you smoke or vape marijuana?","type":"radiogroup","required":true,"page":12,"choices":["Yes","No"]},{"name":"have_you_been_treated_for_any_form_of_cancer","title":"Have you been treated for any form of cancer?","type":"radiogroup","required":true,"page":13,"choices":["Yes","No"]},{"name":"have_you_been_treated_for_any_form_of_heart_disease","title":"Have you been treated for any form of heart disease?","type":"radiogroup","required":true,"page":14,"choices":["Yes","No"]},{"name":"have_you_been_treated_for_diabetes","title":"Have you been treated for diabetes?","type":"radiogroup","required":true,"page":15,"choices":["Yes","No"]},{"name":"are_you_looking_for_a_short_term_or_long_term_policy","title":"Are you looking for a short term or long term policy?","type":"radiogroup","required":true,"page":16,"choices":["short term","long term","not sure"]},{"name":"are_you_working_with_one_of_our_agents","title":"Are you working with one of our Agents?","type":"radiogroup","required":true,"page":17,"choices":["Yes","No"]},{"name":"agent_s_name","title":"Agent’s name","type":"text","required":true,"page":18,"visibleIf":"({are_you_working_with_one_of_our_agents} = 'Yes')"}]}