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Due to the complexity of disability insurance proposals, we may need to clarify your responses. As such, please be sure to provide an "accurate" phone number and email address. We do not sell, distribute, spam or solicit your email account, nor give your address to any other party. As such, please provide your fastest email address. Since quality email addresses can accept larger files, we can give you more detailed and helpful information.

This form must be fully completed to receive proposals (no exceptions). It is available in PDF or the electronic format below.

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Prospect Information
First Name: Last Name:
Street Address: City:
State: Zip:
Business Phone:     Mobile Phone:    
Email Address:
Application State: Birth Place:
Date of Birth: MMDDYYYY Gender: Male   Female 
U.S. Citizen: Yes  No  How long has client lived in the U.S.A.
Exact Height: Feet   Inches  Exact Weight:  lbs
Occupation & Title:     Company Name:    
Annual Income: Self Employed? Yes  No 
If self employed:Business StructurePercent owned:
Years with current employer:  Years of Experience in Your Profession: 

Please describe your occupational duties and the percentage of time spent on each duty:


Percent of time client works from home:

Please describe your professional education and/or training:


HAVE YOU (use tab key to type details)

1. Applied for any disability insurance within the last 24 months 

Yes  No 

2. Been declined for any disability insurance in the last 3 years 

Yes  No 

3. Ever collected disability benefits for sickness or injury 

Yes  No 

4. Participated in sky diving, scuba diving, parachuting, racing, mountain climbing, hang gliding, ballooning, rodeos, or competitive skiing 

Yes  No 

5. Ever flown as a pilot, student pilot or crewmember 

Yes  No 

6. Been convicted of a moving traffic violation or had a driver's license revoked or suspended within the past 3 years 

Yes  No 

7. Been convicted or charged with a felony 

Yes  No 

8. In the next year, any intention of traveling or residing outside of the U.S. or Canada 

Yes  No 

9. Do you belong to or intend joining any active or reserve military, naval or aeronautic organization 

Yes  No 

10. Used any form of tobacco or nicotine in the last 12 months 

Yes  No 
WITHIN THE LAST 10 YEARS, HAVE YOU HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING?

11. Disorder of the eyes, ears, nose or throat 

Yes  No 

12. Dizziness, fainting, seizures, headache; speech defect, paralysis, stroke; mental or nervous conditions including anxiety or depression or counseling 

Yes  No 

13. Shortness of breath, persistent hoarsemess or cough, bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder 

Yes  No 

14. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack, or other disorder of the heart or blood vessels 

Yes  No 

15. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, hepatitis, colitis, diverticulitis, hemorrhoids, recurrent indigestion or other disorder of the stomach, intestines, liver or gallbladder 

Yes  No 

16. Sugar, albumin, blood or pus in your urine, venereal disease; stones(s) or other disorder of kidney(s) or bladder 

Yes  No 

17. Diabetes; thyroid, or other endocrine disorders 

Yes  No 

18. Disorder of breasts, reproductive organs, prostate or complications of pregnancy 

Yes  No 

19. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles, bones, spine, back or joints 

Yes  No 

20. Disorder of the skin, lymph glands, cysts, tumors or cancer 

Yes  No 

21. Allergies; anemia or other disorder of the blood 

Yes  No 

22. Have you had any other mental or physical disorders, injuries, sickness or symptoms not asked, which you have been treated for, taken medication for, or for which an ordinarily prudent person would have sought medication, treatment or advice, or counseling during the last 10 years 

Yes  No 
Other than noted above, have you within the past 5 years:

23. Had any check-ups, pap tests, consultations, illness, injury, or surgery; been a patient in a hospital, clinic, sanatorium, or other medical facility; had any EKG, ECG, X-ray or other diagnostic test(s) 

Yes  No 

24. been medically advised to have any diagnostic test, hospitalization, or surgery which is not yet completed 

Yes  No 
Within the past 10 years have you ever:

25. Used marijuana, cocaine, barbiturates, tranquilizers, heroin, LSD, amphetamines, morphine, narcotics or any other drugs, except as legally prescribed by a physician 

Yes  No 

26. Sought or received medical treatment or professional advice, or been arrested for the use of alcohol, cocaine, marijuana, narcotics or any other drugs 

Yes  No 
Other:

27. Use of alcoholic beverages (type & quantity per week) 

Yes  No 

28. Been diagnosed as having AIDS, ARC or HIV 

Yes  No 

29. Are you now under observation or receiving medical treatment  

Yes  No 

30. Are you pregnant, if yest what is your due date  

Yes  No 

31. Have you had a change in weight in the last 12 months, if "yes", what amount gained or lost  

Yes  No 

32. Do you have a doctor appointment scheduled in the next 6 months, if "yes" what is the reason and who is the doctor  

Yes  No 

33. Do you exercise, if "yes" provide details  

Yes  No 

34. Do you take vitamins or any food supplements, if "yes" provide details  

Yes  No 

35. DO YOU HAVE ANY PRIVATE DISABILITY INSURANCE NOW IN FORCE (If "yes", list below)  

Yes  No 
Insurance CompanyMonthly BenefitWaiting PeriodBenefit PeriodWill this coverage be cancelled or replaced
Private PlanYes  No 
Private PlanYes  No 
Private PlanYes  No 

36. DO YOU HAVE ANY GROUP DISABILITY INSURANCE NOW IN FORCE (If "yes", list below)  

Yes  No 
Who pays for the cost of this coverage?Monthly Benefit (%)Waiting PeriodBenefit PeriodWill this coverage be cancelled or replaced
Group PlanYes  No 
Group PlanYes  No 
Group PlanYes  No 

HAVE YOU CONSIDERED THE DIFFERENCE BETWEEN GROUP AND INDIVIDUALLY OWNED DISABILITY COVERAGE?

Group Coverage or Trade Association Coverage Individually Owned Coverage
  • Can be cancelled anytime by the employer or the insurance company
  • Guaranteed renewable to age 65, conditionally renewable for lifetime
  • Noncancelable by the insurance company as long as premiums are paid on time within the grace period
  • Terminates when you change jobs
  • Terminates when you reduce hours to work part-time
  • Terminates when you are no longer a member
  • Remains in force when you change jobs or occupations
  • Remains in force regardless of the hours you work
  • Does not require membership
  • You do not own the policy
  • Policy is owned by the employer or trade association
  • You do not choose the policy provisions or quality
  • You own the policy
  • You choose the policy provisions and quality level
Definition of disability:
  • During the first 24 month injury or sickness prevents you from performing the duties of your own occupation.
  • After 24 months injury or sickness prevents you from performing the duties of any gainful occupation
Definition of disability:
  • Injury or sickness prevents you from performing the duties of your own occupation
  • Benefits stop if you are able to earn income from some other occupation
  • Benefits continue if you are able to earn income from some other occupation
  • Benefits continue if you do earn income from some other occupation
Benefits automatically reduced if you collect from:
  • Workers compensation
  • Social security disability
  • State disability benefits
Benefits not automatically reduced by other sources:
  • You choose whether or not to integrate with these sources at the time you purchase your policy
Benefits received during disability are taxable to you Benefits received during disability are tax-free.
BUSINESS OVERHEAD EXPENSE INSURANCE

Please answer the following questions:

Note: If you have partners that share these expenses, only include your portion of these expenses which you are responsible for.

How many employees do you have?
How many of them are in your same profession/occupation?
How many partners do you have excluding yourself?
Please "estimate" the following "monthly" expenses:
Covered Business Overhead ExpensesMonthly Amount
Electric Utilities
Gas, oil or propane utilities
Water & sewer utilities
Garbage & waste utilities
Telephone utilities
Wages & salaries for your employees (excluding you)
Cost of employee benefits like health insurance
Janitorial & cleaning services
Laundry & maintenance services
Property insurance
Liability insurance & malpractice insurance
Rent for your building or office space
Principal payments on your mortgage (business premises)
Interest payments on your mortage (business premises)
Realestate taxes on your business premises
Accounting fees
Legal fees
Equipment & furniture leasing payments
Principal payments on business loans or lines of credit
Interest payments on business loans or credit lines
Monthly Combined Expenses

If any of these expenses are reimbursed to you, give complete details below:


Special Instructions or Concerns:


  


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