Disability Insurance Onboarding Form

Disability Insurance Onboarding Form

Please complete the below fields to obtain a proposal for Disability Insurance.
Agency Name
Full Name
Customer Type Monday.com
Monday.com Policy
First Name*
Last Name*
Your Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
State of Residence*
Current MM Customer*

YesNo
Occupation - Be Very Specific (Ex: Orthopedic Surgeon NOT Physician)*
I understand that the SHORTER the Waiting Period and the LONGER the Benefit Period, the More Expensive the Premium will be.*

I Understand
Desired Waiting Period (The amount of time you have to be disabled before payments begin to be made - Also know as Time Deductible).*
Desired Age Of Expiration (The age that your disability benefits will pay until).*
Prior Year Income*

W2 Income1099 Income
W2 Income Amount*
1099 Income Amount*
Are You Currently Self Employed?*

YesNo
How Long Have You Been Self Employed?*
Do You Use Tobacco Or Nicotine In Any Form*

YesNo
What Type & Frequency Of Use
I understand if I have Pre-Existing Medical or Physical Condition(s), there could be an Additional Premium Charge or the Condition/Impairment could be Excluded from the Disability Policy.*

I Understand
I have concerns about my Pre-Existing condition(s) and I would like to disclose them now to ensure an accurate proposal.*

YesNo
Please describe the Pre-Existing Condition(s)*
(Note: The underwriting process for Disability Insurance can be extensive. Please allot a minimum of 45 Days for the policy to take effect. More complicated cases can be in excess of 180 days of underwriting.)
Should be Empty: