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Individual Disability Application

Please fill this out in its entirety and our team will get your application submitted as soon as possible.

Applicant

First Name

Middle Name

Last Name

Date of Birth

Driver's License Number

Social Security Number

Email Address

Primary Phone Number

Birth State

Birth Country

Mailing Address

Street Address

City

State

Zip Code

Is your home address different from your mailing address?

Tobacco & Nicotine

Have you used tobacco and/or nicotine of any form in the last 12 months?

Occupation

Your occupation class is the single biggest factor in disability pricing, so the duties matter as much as the title. Be specific about what you actually do day to day.

Job Title / Occupation

Description of Job Duties

Income

Disability benefits are set as a percentage of earned income, so these three years decide the maximum benefit you can be issued.

Desired monthly benefit

Is unearned income over 20% of your income?

Is your net worth, excluding your primary residence, greater than $10,000,000?

Current calendar year earned income

Prior calendar year earned income

Two years prior calendar year earned income

Health History

The carrier orders your medical records, so everything here surfaces either way. Telling us now means we aim at the right carrier the first time rather than finding out after an application is already in.

Height

Weight

Are you taking any medications?

Do you see a chiropractor?

Do you currently have a diagnosis for anything that would show up in your records?

Have you been to the doctor for anything over the last few years?

Any surgeries?

Anything Else

Anything else we should know?