Personal Information First Name (required) Last Name (required) Phone Number (required) Your Email (required) Birth date (mm/dd/yyyy) Your Gender (required) —Please choose an option—Malefemale Height (example 5'8") Weight (lbs) Who referred you? Underwriting InformationOccupation (if medical, specify specialty) Work related travel —Please choose an option—less than 15 days per year16-30 days per year30-60 days per yearmore than 61 days per year work related travel locationsBase Salary Bonus/Commission Income Do you have coverage at work —Please choose an option—yesnoIf so, what percent of income is covered If so, what is the maximum monthly benefit If so, Does the policy cover bonus/commission income If so, who pays for the coverage—Please choose an option—employeeemployerDo you have a pilot license of any type —Please choose an option—YesNo If yes, what type Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, ect. —Please choose an option—YesNoHave you had your drivers license suspended or revoked —Please choose an option—YesNoHave you been convicted of a felony —Please choose an option—YesNoHave you received disability compensation —Please choose an option—YesNoHave you been advised by a physician to reduce your alcohol consumption —Please choose an option—YesNoDo you smoke or chew tobacco —Please choose an option—YesNoHave you used any illegal narcotics —Please choose an option—YesNoIs your health impaired in any way —Please choose an option—YesNoAre you taking medication —Please choose an option—YesNoDo you have high blood pressure? —Please choose an option—YesNoDo you have asthma, emphysema or respiratory problems —Please choose an option—YesNoDo you have cancer or other tumors —Please choose an option—YesNoDo you have diabetes —Please choose an option—YesNoDo you have AIDS, HIV —Please choose an option—YesNoHave you ever been declined life,health or disability insurance —Please choose an option—YesNoAre you a U.S. citizen —Please choose an option—YesNoRemarks Coverage InformationAnnual Gross salary including tips, fees, and commissions How long have you been employed at your present occupation What percentage of your income do you want your disability policy to cover —Please choose an option—50%60%65%70%How long do you want the elimination period to be (length of time you must be disabled before you start to receive benefits) —Please choose an option—30 days60 days90 days6 months1 year2 yearsHow long do you want the benefit period to be (maximum length of time you will receive benefits after you have been classified as being disabled and satisfied the elimination period) —Please choose an option—2 years3 years4 years5 yearsUntil age 65Are you self-employed —Please choose an option—YesNoWhat is your occupation Please describe your duties at your current job Please explain your reason for purchasing disability insurance —Please choose an option—YesNoDo you currently have disability insurance —Please choose an option—YesNoIf yes, how much Questions or Comments
