Smart Income Protection

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Date of Birth* This field is required.

Birthday (mm-dd-yyyy)

4

Gender* This field is required.

Male

Female

5

Height

6

Weight

7

State of Residence* This field is required.

8

Have you used any nicotine products in the last 12 months?* This field is required.

YESNO

9

Occupation* This field is required.

If Dr. include specialty and hospital affiliation

10

DutiesIncluding number of hours working per week, length of employment

11

Are you a business owner?* This field is required.

YESNO

12

What type of business?

13

Number of W2 employees

14

How long have you owned the business?

15

Income* This field is required.

16

Bonus Income

17

Did you file for bankruptcy in the past 10 years?

YESNO

18

Group coverage details

to include % of income, cap, paid for by

19

Any insurance coverage applied for and declined or not issued as applied for in the past 5 years?* This field is required.

YESNO

20

Medical history details

All Dr visits in the past 5 years including any surgery, medications, chiropractor treatment, mental health treatment.

21

Do you participate in any recreational/ hazardous sports?* This field is required.

YESNO

22

Do you have any disability income coverage in force, either individually or through work?* This field is required.

YESNO

23

Any Dr visits in the past 5 years, including any surgery, medications, chiropractor treatment, mental health treatment other than routine physicals?* This field is required.

YESNO