DISABILITY INSURANCE APPLICATION
Applicant Information
Name
First Name
Middle Initial
Last Name
Suffix
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone #
Format: (000) 000-0000.
Height
Weight
Birth Country
Birth State
Occupation and Income
Please add each current occupation where you work 6 or more hours per week. You may provide up to five occupations, if applicable.
Occupation 1
Job Title / Occupation
Type of Work Performed
Hours per Week
Years in Occupation
Type of Business / Industry
Total Annual Net Income After Taxes ($)
Employer / Business Name
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DISABILITY INSURANCE APPLICATION
Occupation 2
Job Title / Occupation
Type of Worker
Rows
Hours per Week
Years in Occupation
Years of Ownership
1
Type of Business / Industry
Ownership %
Total Annual Net Income After Taxes ($)
Employer / Business Name
Occupation 3
Occupation 3
Rows
Job Title / Occupation
Type of Worker
1
Rows
Hours per Week
Years in Occupation
Years of Ownership
1
Type of Business / Industry
Ownership %
Total Annual Net Income After Taxes ($)
Employer / Business Name
Occupation 4
Job Title / Occupation
Type of Worker
Occupation 4
Rows
Hours per Week
Years in Occupation
Years of Ownership
1
Type of Business / Industry
Ownership %
Total Annual Net Income After Taxes ($)
Employer / Business Name
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DISABILITY INSURANCE APPLICATION
Occupation 5
Job Title / Occupation
Type of Worker
Hours per Week
Years in Occupation
Years of Ownership
Type of Business / Industry
Ownership %
Total Annual Net Income After Taxes ($)
Employer / Business Name
Unearned Income
Do you have any unearned income, such as capital gains, interest, dividends, rental income, pensions, annuities, or alimony?
Yes
No
If Yes, describe the source(s) and approximate annual amount.
Identity Verification
Do you have a valid driver's license?
Yes
No
Driver's License Number
Issuing State
Social Security Number
Current Work Status
During the past six months, have you been working continuously at least 30 hours per week, and are you currently working at least 30 hours per week?
Yes
No
If No, explain any periods not worked and the reason.
During the past six months, have you been limited in your ability to perform regular occupational duties or work regular hours due to a physical, mental, or psychological impairment?
Yes
No
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If Yes, describe the limitation, dates, and impact on your work duties or hours.
Lifestyle and Citizenship
During the past 12 months, have you used any form of tobacco or nicotine-based products, including substitutes such as patches or gum?
Yes
No
If Yes, list product/type, frequency, and date last used.
During the past 12 months, have you used any form of marijuana or product containing THC?
Yes
No
If Yes, describe type, frequency, reason for use, and date last used.
Are you a United States citizen or permanent resident?
Yes
No
If No, describe your current immigration/residency status.
Avocations, Travel, and Military Service
During the past 12 months, have you engaged in, or do you intend within the next 12 months to engage in any of the following activities?
Motorized sports
Rock / mountain / ice climbing
Skin / scuba diving
Cave exploration
Boxing
Rodeo
Semi-professional / professional sports
None of the above
If any activity applies, provide details, frequency, location, and experience.
Are you currently, or have you entered into a written agreement to become, a member of the military or an active duty member of the National Guard?
Yes
No
If Yes, provide branch, status, duties, and anticipated deployment information, if applicable.
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DISABILITY INSURANCE APPLICATION
Do you currently hold any type of pilot's license or intend to pursue a pilot's license within the next 12 months?
Yes
No
If Yes, provide license type, annual flight hours, aircraft type, and purpose of flying.
During the past 12 months, have you engaged in, or do you intend within the next 12 months to engage in, any of the following aeronautics or aerial activities?
Hang-gliding
Ballooning
Sky diving
Bungee jumping
Parachuting
None of the above
Ultralight soaring
If any activity applies, provide details.
During the past 12 months, have you traveled or lived outside the United States, or do you intend to travel or live outside the United States within the next 12 months?
Yes
No
If Yes, list country/countries, dates, duration, and purpose.
Driving, Criminal History, and Bankruptcy
In the past 5 years, has your driver's license been suspended or revoked; have you pleaded guilty to or been convicted of driving while impaired, intoxicated, or under the influence of any drug; or have you pleaded guilty to or been convicted of more than 3 moving violations?
Yes
No
If Yes, provide date(s), offense/violation(s), and disposition.
In the past 10 years, have you pleaded guilty to or been convicted of a felony or misdemeanor?
Yes
No
If Yes, provide date(s), offense(s), and disposition.
Have you ever filed for personal or business bankruptcy?
Yes
No
If Yes, provide type, filing date, and discharge/status date.
Other Disability Coverage and Benefits
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DISABILITY INSURANCE APPLICATION
Are you currently receiving any type of disability benefits or currently in the process of applying for any type of disability benefits, including Social Security or workers' compensation?
Yes
No
If Yes, identify the benefit, monthly amount, status, and start/application date.
Do you have any other disability income insurance coverage in force?
Yes
No
If Yes, list carrier, monthly benefit, benefit period, elimination period, and policy number if available.
Medical History - Serious Conditions
In the last 10 years, have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for any of the following?
Alzheimer's Disease
Insulin-dependent Diabetes
Multiple Sclerosis
Muscular Dystrophy
Parkinson's Disease
Amyotrophic Lateral Sclerosis (ALS)
Cystic Fibrosis
Cirrhosis of the liver
Polycystic Kidney Disease
Hemophilia requiring replacement therapy
Personality disorders
Psychotic disorders or Schizophrenia
Myasthenia Gravis
HIV or AIDS
Guillain-Barre Syndrome
Organ transplant of any type
None of the above
For each item checked, provide condition, date diagnosed, treatment, current status, medications, and treating provider.
In the last 10 years, have you been diagnosed, treated for, or been given medical advice by a member of the medical profession for non-insulin-dependent diabetes?
Yes
No
If Yes, provide date diagnosed, treatment/medications, most recent A1C if known, complications, and treating provider.
Drug and Alcohol History
In the last 10 years, have you used any of the following except as prescribed by a physician?
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In the last 10 years, have you used any of the following substances?
Narcotics
Opioids
Benzodiazepines
Barbiturates
Amphetamines
Hallucinogens
Heroin
Cocaine
Any other habit-forming drug
None of the above
If any item applies, provide substance, dates/frequency of use, date last used, and any treatment received.
In the last 10 years, have you received medical treatment or counseling for, or been advised by a physician to discontinue, the use of alcohol or prescribed/non-prescribed drugs?
Yes
No
If Yes, provide dates, reason, treatment/counseling, and current status.
Activities of Daily Living
In the last 10 years, have you needed assistance or supervision to perform any activities of daily living, including toileting, transferring, continence, eating, bathing, or dressing?
Yes
No
If Yes, identify the activity, reason, dates, and whether assistance is still required.
Medical History - Other Conditions
In the last 10 years, have you been diagnosed, treated, or been given medical advice by a member of the medical profession for any of the following?
Heart attack
Heart disease
Angina
Uncontrolled hypertension
Chronic lung disease
Mental / nervous disease or disorder
Stroke
Internal cancer or melanoma (excluding basal or squamous cell skin cancer)
Disease/disorder of the stomach, intestine, bowel, or rectum
None of the above
For each item checked, provide condition, diagnosis date, treatment, medications, current status, and treating provider.
Musculoskeletal History
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DISABILITY INSURANCE APPLICATION
In the past 12 months, have you been diagnosed, treated, or been given medical advice by a member of the medical profession for any disease or disorder of the following?
Spine
Bones
Joints
Muscles
None of the above
If any item applies, provide diagnosis, body area, dates, treatment, work restrictions/limitations, time missed from work, and current status.
Recent Infectious Disease Hospitalization
In the past 6 months, have you been hospitalized for any infectious disease, including:
COVID-19 (Coronavirus)
Ebola
MRSA
SARS
MERS
Zika
Other infectious disease
None of the above
If any item applies, provide diagnosis, hospitalization dates, treatment, complications, and current status.
Upcoming Procedures and Pending Tests
In the next 6 months, do you have any surgeries or other medical procedures scheduled, or have you been advised by a member of the medical profession to have a surgery or other medical procedure?
Yes
No
If Yes, provide procedure, reason, scheduled/anticipated date, and provider.
In the past 12 months, have you been advised by a member of the medical profession to complete any diagnostic or screening tests that have not been completed, or for which results have not been received?
Yes
No
If Yes, provide test, reason, date recommended/performed, and status/results if now available.
Additional Disability Underwriting Information
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DISABILITY INSURANCE APPLICATION
In the past 5 years, have you had any surgery, hospitalization, emergency room visit, or overnight observation not already disclosed in this application?
Yes
No
If Yes, provide date, reason/diagnosis, facility/provider, treatment, and outcome.
In the past 5 years, have you missed more than 5 consecutive workdays because of illness or injury, or had your work duties/hours restricted for medical reasons?
Yes
No
If Yes, provide dates, condition/injury, time missed, restrictions, and current status.
Have you ever filed a disability income, workers' compensation, Social Security disability, or similar income-replacement claim not already disclosed?
Yes
No
If Yes, provide claim type, date, reason, benefit period, amount if known, and outcome/status.
List all current prescription or maintenance medications not already disclosed, including medication name, dosage, frequency, and the condition/reason taken.
List primary care physician and any specialists seen in the past 5 years (name, specialty, city/state, phone if known).
Applicant Certification and Signature
I certify that the information provided in this application is complete and accurate to the best of my knowledge. I understand that this form is intended to collect preliminary application information and that an insurance carrier may require additional questions, authorizations, medical records, financial documentation, or carrier-specific forms before coverage can be issued.
Applicant Full Name (type name)
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional information or explanations
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Coverage & Financial Information
Disability Insurance Application - Additional Information
Page 10
Additional Client Information
Birthdate (MM/DD/YYYY)*
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender*
*
Male
Female
Bonuses - annual amount, if applicable
Please describe your occupation and regular job duties.
Total average monthly personal and/or business expenses
Plan Design - Personal Disability Income
Elimination Period
Benefit Period
Plan Design - Business Overhead Expense
Elimination Period
Benefit Period
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Benefit Selection & Optional Riders
Disability Insurance Application - Additional Information
Page 11
Monthly Benefit
Desired Monthly Benefit Amount ($)
Quote maximum available benefit?
Yes
No
Premium Mode*
*
Annual
Semi-Annual
Quarterly
Monthly
Optional Benefits / Riders
Cost of Living Adjustment (COLA)?
Yes
No
Return of Premium?
Yes
No
Accidental Death?
Yes
No
Guaranteed Insurability Option Rider?
Yes
No
Activities of Daily Living benefit/rider?
Yes
No
Additional Information
Additional comments, health concerns, requested benefits, or other information:
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Coverage Selection Details
Disability Insurance Application - Additional Information
Page 12
Plan & Rider Details
If you selected a specific elimination period or benefit period, explain any preferences or priorities:
If Business Overhead Expense coverage is requested, describe the business and the expenses you want covered:
If an insurance agent is assisting you, what is their name?
Please Select
Not Sure / No One Yet
Lisann Taylor
Brett Garner
John Hadder
Bo Davenport
Dionne Thomas
Applicant Notes
Use this area for any information that may help the agent or carrier understand your requested disability coverage.
Applicant Notes
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