Name: 

*

Address: 

City: 

State: Zip:

Phone: 

Work : 

*

Home : 

Fax : 

Email: 

*

Gender: 

Male Female

Date of Birth: 

Month 1 2 3 4 5 6 7 8 9 10 11 12 / 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 /

Height: 

Feet 3' 4' 5' 6' 7' Inches 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"

Weight: 

Occupation: 

Are you self employed? 

Yes No

If not, Who is your employer? 

What is your position? 

How many years have you been with your current employer?

1 - 3 Years 3 - 6 Years 6 - 10 Years 10 - 15 Years 15 - 25 Years 25 + Years

What is your monthly gross income?

$

What is the monthly benefit you are requesting?

$

Health Information

Please indicate your tobacco use: 

None Cigarettes Cigars Chewing tobacco Pipe

Do you participate in any hazardous activities? 

None Scuba Private Pilot Auto/Motorcycle Racing Other

Please describe any health problems : (leave it blank, if not applicable) 

Please list any medications you are taking : (leave it blank, if  not applicable) 

Describe your family's history of cancer and/or heart disease : (leave it blank, if not applicable)  

Insurance Coverage

For what period of time will you need benefits?

Select One 1 Year 2 years 3 Years 5 Years To Age 65

After Disability, When should benefits be scheduled to begin?

Select One 30 Days 60 Days 90 Days 180 Days 365 Days