Date of Birth
  Month January February March April May June July August September October November December           Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , Year (ex. 1950)

Gender:
Male   Female

Have you used tobacco products or nicotine substitutes in the past 12 months?
  Yes   No

Do you take any medications?
  Yes   No

If "YES," please give details, dates, history and reason:

Other than shown above, do you have any other medical condition or history for which you have had surgery, been hospitalize, or seen a physican in the last 3 years?
  Yes   No

If "YES," please give details:

Are you self employed?
Yes   No

If "YES" are you?
NA Partnership Sole Proprietorship Corporation S Corporation LLCS or LLPS

Annual Income-Salaried (W2 or 1099) or Self-Employed (Net Business earnings; Schedule C or K; or net share of corporate earnings) 
 $ (ex. 10000)

Are you a City, State of Federal Employee?
No Yes

If "YES." how many years? 

What is your Occupation?
       Please note: Physicians please provide your specialty.

Please describe your duties at work.
                                                                       % of Time:
Task 1:      10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Task 2:      10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Task 3:      10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Where is your office location?
Home   Outside   Both

If HOME or BOTH what % of time do you work at home?
NA 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

This section helps determine if you are interested in getting new disability coverage or adding to existing disability coverage.

Do you have any existing disability income coverage?
Yes   No

If "YES,"

                       Type of Coverage:

                             Group    Individual

                       Benefit amount per month?

                           $  (ex. 5000)

                        Benefit Period:
                               (ex. 6 months)

Replace or Add to existing coverage?
New Coverage Replace Existing Coverage Add to Existing Coverage

Desired Coverage?
  per month.  (ex. 5000)

Benefits to begin:
60 days 90 days 180 days 360 days after disability.

Pay benefits:
Age 65 for 5 years for 2 years