First Name:
Last Name:
Address – Street:
City:
State:
Zip:
Day Phone:
Evening Phone:
Cell Phone:
E-mail address:
Repeat e-mail:
Birthdate:
Height:
Weight:
Male Female
Benefit period preferred:
Maximum monthly premium you would consider:
Have you had a prior decline for disability insurance? Reason, if known:
Will an employer pay the premium? Yes No
Monthly benefit wanted:
Tobacco use - type, amount, date of last use / never:
Medical conditions last 5 years (include mental health, HBP, cholesterol, etc.):
Physical impairments:
Medications prescribed in last year + dosage:
Been resident in a nursing home? When, reason?
History of alcohol or substance abuse/treatment:
List any risky sports/hobbies or hazardous occupations (includes private pilot):
Last 5 years, list DUI, license suspension/revocation, or other moving violations:
Foreign travel planned in the next two years:
If self-employed, average annual taxable income in the last two years:
Whether employed or self-employed, approx. current annual earnings:
% of work done at home:
Self-employed?
Yes
No
C corp?
Yes
No
Describe occupation, specific duties, type of location, # years at occupation:
Government employee? Yes No
#Years: Type:
Covered by group disability insurance? Yes No Monthly benefit : $
Benefit as % of earnings 60% 67% Employer Paid? Yes No
Have current individual disability insurance? Yes No Monthly benefit:
To remain in force? Yes No
U.S. citizen/resident? Yes No
Active military duty now/soon? Yes No
Insurers preferred, if any; other comments:
All quotes are based on a risk category assumed on the basis of the information given.