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Disability Insurance - Questionnaire


Please complete the form below.

(* indicates a required field)

Name: *
Clinic Name:  
Occupation/Specialty *
 
Phone: *
Fax:  
E-Mail: *
 
Address: *
City: *
State: *
Zip code: *
 
Date of Birth: *
Gender: *  Male
 Female
 
Smoker: *  Yes
 No
 
Annual earned income:  
 
Number of hours worked
per week:
   Less than 30
 More than 30
 
Current Disability Insurance Coverage

Type of plan: *  Group
 Individual
 
Monthly benefit:  
 
Elimination period (days):    30
 60
 90
 180
 
Benefit period:    2Yr
 5Yr
 Age 65
 
Supplemental Benefits
 
 Own occupation coverage
 Future purchase option
 Residual (Partial)
 Indexed Cost of Living
 
Comments:
 
 

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