Disability Insurance Questionnaire

Information

First Name *

Middle Name

Last Name *

Primary Phone

Cell Phone *

Work Phone

E-mail Address *

Address *

City *

State *

Zip *

Gender *

Male

Female

Other

Date of Birth *

State of Residence

State of Birth

Country of Birth (If Not U.S.)

Are You A U.S. Citizen or Permanent Resident / Green Card Holder

Yes

No

List Country of Citizenship

Visa

Have You Used Tabacco or Tabacco Products in The Last 5 Years?

Yes

No

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last used?

On average, how many per day

Date you last used?

On average, how many per day

Height

Weight (lbs)

Are You A Physician?

Yes

No

What is Your Current Occupation?

Do You Have Student Debt?

Yes

No

Approximate Balance of Student Debt

Student Debt Monthly Payment

Who Is Your Current Employer? (This helps us find potential discounts)

Please List Your Current Speciality

Are You in Training

Yes

No

Please List the Name of Your Employer/Practice/Hospital/GME Program

What Is Your PGY

Are You in Medical School?

Yes

No

What Is The Name of Your Medical School?

When Do You Complete Medical School

Are You an Attending Physician?

Yes

No

How Meny Years Have You Been an Attending Physician?

When Did You Complete Training

When Did You Start as an Attendin Physician?

What Is Your Current Speciality

Individual Annual Income or Salary (Do Not Include Spouse or Partner)

Do You Own Any Part of or are You an Independent Contractor for the Business Where You Work? *

Yes

No

Percentage of Business Entity Owned (C Corp)

Percentage of Business Entity Owned (LLC)

Percentage of Business Entity Owned (S Corp)

Percentage of Business Entity Owned (LLP)

Percentage of Business Entity Owned (Sole Proprietorshop)

Percentage of Business Entity Owned (Partnership)

Percentage of Business Entity Owned (Other)

Explain

Years Owned

History

PLEASE LIST ANY INDIVIDUAL DISABILITY INSURANCE COVERAGE YOU OWN

Company

Monthly Benefit

PLEASE LIST DETAILS OF ANY EXISTING EMPLOYER GROUP LTD COVERAGE

Company

Coverage

MONTHLY BENEFIT

Monthly Benefit

OR

Coverage Percently

OF SALARY TO A MONTHLY MAX OF

% Of Income

To a Maximum Monthly Cap of:

When Did You Last See a Doctor

For What reason/Condition Did You Last See The Doctor? Please Note The Findings/Results of Your Visit

PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING

NAME OF MEDICATION/ DATE STARTED/ CONDITION/REASON AND & DATE OF DIAGNOSIS/ DOSAGE/ FREQUENCY

Medication 1

Medication Name *

Condition/Reason *

Date of Diagnosis

Dosage (mg)

Frequency

Medication 2

Medication Name *

Condition/Reason *

Date of Diagnosis

Dosage (mg)

Frequency

Medication 3

Medication Name *

Condition/Reason *

Date of Diagnosis

Dosage (mg)

Frequency

Medication 4

Medication Name *

Condition/Reason *

Date of Diagnosis

Dosage (mg)

Frequency

Medication 5

Medication Name *

Condition/Reason *

Date of Diagnosis

Dosage (mg)

Frequency

Medication 6

Medication Name *

Condition/Reason *

Date of Diagnosis

Dosage (mg)

Frequency

PLEASE LIST ANY DIAGNOSED/KNOWN HEALTH ISSUES OR RELEVANT HEALTH INFORMATION

PLEASE LIST DETAILS OF ANY SURGERIES YOU HAVE UNDERGONE AND DATE(S)

ARE YOU NOW OR IN THE PAST 7 YEARS HAVE YOU SEEN/CONSULTED WITH A CHIROPRACTOR?

Yes

No

Please Note Reason, Treatment and Date of Last Service

ARE YOU NOW OR IN THE PAST 7 YEARS HAVE YOU SEEN/CONSULTED WITH A PSYCHIATRIST OR PSYCHOLOGIST?

Yes

No

Please Note Reason, Treatment and Date of Last Service

FAMILY HISTORY

DOES EITHER PARENT OR ANY SIBLING HAVE A HISTORY OF CARDIOVASCULAR DISEASE WHICH WAS DIAGNOSED BEFORE AGE 70?

Sibling(s)

Mother

Father

TYPE OF CARDIOVASCULAR DIAGNOSIS (Father)

TYPE OF CARDIOVASCULAR DIAGNOSIS (Mother)

TYPE OF CARDIOVASCULAR DIAGNOSIS (Siblings)

DOES EITHER PARENT OR ANY SIBLING HAVE A HISTORY OF CANCER WHICH WAS DIAGNOSED BEFORE AGE 70?

Sibling(s)

Mother

Father

TYPE OF CANCER DIAGNOSIS (Father)

TYPE OF CANCER DIAGNOSIS (Mother)

TYPE OF CANCER DIAGNOSIS (Siblings)

ARE YOU CONSIDERING REPLACING YOUR CURRENT INSURANCE POLICY?

NO

YES

HAVE YOU HAD YOUR DRIVER’S LICENSE SUSPENDED OR REVOKED OR HAD MORE THAN ONE TICKET OR ACCIDENT IN THE PAST 5 YEARS?

NO

YES

Have you been convicted of drunk driving (DUI/DWI) in the last 10 years

YES

NO

When was your most recent conviction for drunk driving (DUI/DWI)?

Have you been convicted of reckless driving in the last 10 years?

YES

NO

When was your most recent conviction for reckless driving?

Has your license been revoked or suspended in the last 10 years?

YES

NO

When was your most recent conviction resulting in a revoke or suspension driver's license??

Have you had any moving violations over the past 5 years

YES

NO

Total number of moving violations during the last 6 months

Total number of moving violations during the last year, more then 6 months

Total number of moving violations during the last 2 years, more then 1 year ago

Total number of moving violations during the last 3 years, more then 2 years ago

Total number of moving violations during the last 5 years, more then 3 years ago

PLEASE LIST ANY ADDITIONAL INFORMATION YOU FEEL MIGHT BE HELPFUL TO US IN QUOTING YOUR INSURANCE

Who were you referred by?

Relationship to you

Other relatioship

MONTHLY BENEFIT

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