Your Information

First Name

Last Name

Email Address

Phone Number

Gender

FemaleMale

Birthday

State

Height

Weight (in lbs)

What type?

How often?

Known health conditions

Over 40% of disability applications are missing key health history details, leading to policies not being approved as submitted. Eliminate any surprises by accurately completing the questions below.

Are you currently taking any medications?

YesNo

Please list all medications and the length of time on each.

Neck or back disorders

YesNo

Depression or anxiety

YesNo

Diabetes

YesNo

Sleep apnea

YesNo

Cardiac conditions

YesNo

Cancer

YesNo

Are there any other known health conditions for which lengthy treatment was needed?

YesNo

Please provide details on the conditions marked "yes" above.

Occupation details

Occupation

Length of Time at Current Employer

Are you a government employee?

YesNo

Are you a business owner?

YesNo

Number of full-time employees

How long have you been self employed?

Monthly Expenses

Earnings and current coverage

Current year's gross earnings

Last year's gross earnings

Gross earnings two years ago

Do you have existing group disability coverage?

YesNo

Do you have existing individual disability coverage?

YesNo

Existing group disability insurance

Existing elimination period

Existing benefit period

Existing individual disability coverage

Exisiting elimination period

Existing benefit period

Will existing coverage be replaced?

YesNo