|
First
Name
|
Last
Name
|
|
Email
|
Date
of Birth
|
|
Phone
Number
|
Fax
Number
|
|
Smoke Yes
No
|
Male
Female
|
|
Personal
Buy
|
Employer
Buy
|
|
Annual
Earnings:
(NET after business expenses - before taxes.)
|
(2001)
(2000)
(1999)
|
|
Specific
Daily Duties: Be as detailed as possible, this
will achieve the best class/rate. (If M.D.,
please specify specialty / if Self -Employed,
give details.)
|
|
Is
Travel Required?
Yes
No
|
If "Yes", % of time & destination
|
|
How
long in current position / Self-Emp.?
|
|
Any
other disability coverage?
Group
Individual
|
If "Yes",
provide details:
|
|
|
|
|
FOR
BUSINESS OWNERS ONLY:
|
|
%
of ownership
|
"S" Corp.
"C" Corp.
(choose one) |
|
#
of FT employees
|
Outside
Office (Off-residence property)
Yes
No
|
|
Position
(i.e., Manager, Owner, etc...)
|
|
|
|
|
|
|
|
FOR
PERSONAL & BUSINESS DISABILITY
|
|
Specific
Requests: (include benefit amount, waiting
period, benefit period, riders, other)
|
|
Health
History (ANY/ALL health issues should be disclosed
for best consideration)
|
