The American College of Surgeons Insurance Program
Serving The Needs of Surgeons For Over 65 Years
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Home
Group Insurance Plans
Supplemental Disability Income
Level Term Life
Traditional Term Life
Long Term Disability
Short-Term Disability
Office Overhead Disability
Accidental Death
Other Insurance Plans
ID Theft Protection
Personal Umbrella Insurance
Long Term Care
Medicare Supplement Exchange
Manage Your Policy
Bank Draft Authorization
Change of Information Form
Request Other Forms or Information
Claim Forms
Request For Information
Request For Rate Quote for Group Insurance Plans
Full Name
*
Email Address
*
Date of Birth
*
Month
Month
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Feb
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Year
Year
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2018
2019
State of Residence
*
Gender
*
Male
Female
Are you requesting a quote for your spouse as well?
*
Yes
No
Spouse's Date of Birth
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
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11
12
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16
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18
19
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22
23
24
25
26
27
28
29
30
31
Year
Year
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Spouse's State of Residence
*
Spouse's Gender
*
Male
Female
What insurance products are you interested in?
*
Life Insurance
Long-Term Disability Insurance
Office Overhead Expense Disability Insurance
Accidental Death and Dismemberment
Short-Term Disability
Supplemental Disability
Life Insurance
Choose the Life Insurance types you are interested in
*
10 YEAR LEVEL TERM LIFE
15 YEAR LEVEL TERM LIFE
20 YEAR LEVEL TERM LIFE
TRADITIONAL TERM LIFE
Enter the Life Insurance coverage amount you are interested in
*
Indicate if you are interested in the Chronic Care Rider
*
Yes
No
Enter the benefit requested for the Chronic Care Rider
*
Enter the Life Insurance coverage amount you are interested in for your spouse
*
Long-Term Disability
Enter the Long-Term Disability Insurance coverage monthly amount you are interested in
*
Choose the waiting period you are interested in for Long-Term Disability
*
30 Days
60 Days
90 Days
180 Days
Indicate if you are interested in the Future Purchase Option and/or the Cost of Living Adjustment
*
Future Purchase Option (FPO)
Cost of Living Adjustment (COLA)
Not Interested
*If requesting a quote for $20,000 a month in coverage, the Future Purchase Option is not available, as the maximum benefit amount is $20,000
Enter the the coverage amount requested for the Future Purchase Option
*
Please enter an amount up to $7,500
Office Overhead Disability
Enter the monthly coverage amount requested for Office Overhead Disability
*
Accidental Death and Dismemberment
Enter the coverage amount requested for Accidental Death & Dismemberment
*
Hospital Indemnity
Enter the daily benefit requested for Hospital Indemnity
*
Are you interested in Hospital Indemnity coverage for your spouse?
*
- Select -
Yes
No
Enter a Short-Term Disability monthly amount up to $5,000
*
Choose the benefit period you are interested in
*
3-Month
6-Month
Choose the plan/waiting periods you are interested in
*
Plan 1 - 7 Day Accident and Sickness
Plan 2- 30 Day Accident and Sickness
Choose the Supplemental Disability benefit period you are interested in
*
5-Year Maximum Benefit
10-Year Maximum Benefit
Enter the Supplemental Disability Insurance coverage monthly amount you are interested in
*
Additional message or comment
Are you interested in AD&D coverage for your spouse?
- None -
Yes
No
Leave this field blank