Personal Information First Name (required) Last Name (required) Phone Number (required) Your Email (required) Birth date (mm/dd/yyyy) Your Gender (required) ---Malefemale Height (example 5'8") Weight (lbs) Who referred you? Underwriting InformationOccupation (if medical, specify specialty) Work related travel ---less than 15 days per year16-30 days per year30-60 days per yearmore than 61 days per yearwork related travel locations Base Salary Bonus/Commission Income Do you have coverage at work ---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---employeeemployerDo you have a pilot license of any type ---YesNo If yes, what type Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, ect. ---YesNoHave you had your drivers license suspended or revoked ---YesNoHave you been convicted of a felony ---YesNoHave you received disability compensation ---YesNoHave you been advised by a physician to reduce your alcohol consumption ---YesNoDo you smoke or chew tobacco ---YesNoHave you used any illegal narcotics ---YesNoIs your health impaired in any way ---YesNoAre you taking medication ---YesNoDo you have high blood pressure? ---YesNoDo you have asthma, emphysema or respiratory problems ---YesNoDo you have cancer or other tumors ---YesNoDo you have diabetes ---YesNoDo you have AIDS, HIV ---YesNoHave you ever been declined life,health or disability insurance ---YesNoAre you a U.S. citizen ---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 ---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) ---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) ---2 years3 years4 years5 yearsUntil age 65Are you self-employed ---YesNoWhat is your occupation Please describe your duties at your current job Please explain your reason for purchasing disability insurance ---YesNoDo you currently have disability insurance ---YesNoIf yes, how much Questions or Comments
