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Disability Insurance Application
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Name
*
First
Middle
Last
Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Birth State
*
Phone
*
Email
*
Birth Date
*
MM
1
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DD
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YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Sex
*
Male
Female
Monthly Benefit
*
300
400
500
600
700
800
900
1,000
1,100
1,200
1,300
1,400
1,500
1,600
1,700
1,800
1,900
2,000
2,100
2,200
2,300
2,400
2,500
2,600
2,700
2,800
2,900
3,000
3,100
3,200
3,300
3,400
3,500
3,600
3,700
3,800
3,900
4,000
Benefit Period
*
12 months
24 months
36 months
Next
Occupation
*
Annual Earned Income? If self-employed, taxable (net) income
*
For the last 6 months, have you been continuously at work for at least 30 hours per week with your current employer performing all the duties of your occupation?
*
Yes
No
For the last 6 months, have you worked entirely in an office (administrative) setting?
*
Yes
No
Are you currently in the process of filing or had a bankruptcy discharge in the last 2 years?
*
Yes
No
Do you have other disability coverage that will remain in force, which when combined with this applied for coverage, will exceed 70 percent of your annual earned income?
*
Yes
No
Is the coverage applied for replacing any existing coverage for the Proposed Insured?
*
Yes
No
Company Name
*
Benefit Amount
*
Primary Beneficiary
*
Relationship
*
Comments
If you want any more Primary or Contingent Beneficiaries, please add here with name, relationship and percentage. If you have more then 5 children for coverage, please include others here as well. Let us know here If you want Return of Premium added into your plan and your state allows.
Next
1. Are you a U.S. Citizen or a Permanent Resident Card holder who has resided in the U.S. for 3 or more years?
*
Yes
No
2. During the last 12 months, have you used any form of tobacco or any form of nicotine replacement/cessation product (such as nicotine gum, patch, spray, ecig. and vapor)?
*
Yes
No
3. Are you pregnant?
*
Yes
No
4. During the last 12 months, other than for childbirth, have you:
a. Been admitted to a hospital?
*
Yes
No
b. Had surgery, received, or been advised by a member of the medical profession to receive physical or occupational therapy?
*
Yes
No
c. Had 2 or more blood pressure readings over 140/90 taken by a member of the medical profession?
*
Yes
No
5. During the last 2 years, have you been advised by a medical professional to undergo treatment, surgery, procedure, diagnostic evaluation or testing that has not yet been completed or diagnostic tests performed where the results are still pending or were inconclusive?
*
Yes
No
6. During the last 2 years, have you used marijuana in any form for recreational or medical purposes?
*
Yes
No
7. During the last 5 years, have you used narcotics in any form for recreational or medical purposes, cocaine, hallucinogens, barbiturates or other drugs?
*
Yes
No
8. During the last 5 years, have you been declined for any disability or life insurance policy?
*
Yes
No
9. During the last 5 years, have you applied for or received disability benefits?
*
Yes
No
10. During the last 5 years, have you plead guilty to or been convicted of a felony, driving under the influence of alcohol or drugs, been incarcerated or currently on probation or parole?
*
Yes
No
11. During the last 5 years, have you been treated for alcohol use?
*
Yes
No
12. During the last 5 years, have you been diagnosed with or treated for Human Immunodeficiency Syndrome (HIV)/Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?
*
Yes
No
13. During the last 5 years, have you been diagnosed with, received care or treatment, or been advised by a member of the medical profession to seek treatment for or consulted with a health care provider regarding:
Check box to proceed with questions
*
Check box here
a. Manic Depressive Illness (Bipolar), schizophrenia, Post Traumatic Stress Disorder (PTSD)?
*
Yes
No
b. Brain or nerve system disease or disorder, including but not limited to, epilepsy, concussion syndrome (Traumatic Brain Injury), Dementia, Alzheimers, Multiple Sclerosis, Parkinson’s, Amyotrophic Lateral Sclerosis (ALS), neuropathy or stroke?
*
Yes
No
c. Heart or artery disease, disorder or surgery?
*
Yes
No
d. Lung disease or disorder, including but not limited to, chronic bronchitis, emphysema or severe sleep apnea?
*
Yes
No
e. Leukemia, lymphoma, melanoma (except basal cell skin cancer) or any other cancer?
*
Yes
No
f. Musculoskeletal disease or disorder, including but not limited to, fibromyalgia, chronic fatigue, rheumatoid or psoriatic arthritis?
*
Yes
No
g. Treatment or surgery of the spine, neck, back, hip, knee or shoulder?
*
Yes
No
h. Inflammatory bowel disease, including but not limited to, Crohn’s or ulcerative colitis?
*
Yes
No
i. Chronic kidney disease?
*
Yes
No
j. Liver disease, including but not limited to, cirrhosis, hepatitis B or C?
*
Yes
No
k. Organ transplant?
*
Yes
No
l. Diabetes?
*
Yes
No
m. Connective tissue disease or disorder including, but not limited to, Systemic Lupus Erythematosus (SLE), scleroderma or polymyositis?
*
Yes
No
n. Blood disease or disorder, including but not limited to, sickle cell anemia or blood clotting disorder?
*
Yes
No
Height
*
Weight
*
Check box to proceed with application=
*
Check box here
Social Security Number
*
Name of Financial Institution
*
Bank Routing Number
*
Bank Account Number
*
Payment day
*
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*
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*
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