Disability Income Pre-Screening Questionnaire


Agent Information
First Name:  
Last Name:  
Email:  
Phone:  
Fax:  
Date: 11/21/2008  
Client Information
First Name:  
Last Name:  
DOB:  
Sex:  
State:  
Permanent resident/citizen of the United States?  
MEDICAL HISTORY
When was the last time you used tobacco in any form?

Never
 
Height:  
Weight:  
Are you currently taking any medication? If Yes, Explain.
Are you pregnant? (Females Only)  
Do you have a history of:
Neck or Back disorders? If Yes, Explain.
Mental/Nervous conditions? If Yes, Explain.
Diabetes/High Cholesterol/Hypertension? If Yes, Explain.
In the last 5 years, have you seen any:
Physicians If Yes, Explain.
Chiropractors? If Yes, Explain.
Counselors/Psychiatrists? If Yes, Explain.
Please provide details of any other material medical history not disclosed above.
OTHER DISABILITY INCOME INSURANCE:
Do you have any Group Disability Insurance? If Yes, Explain.
Do you have any Individual Disability Insurance? If Yes, Explain.
Do you have any Association Disability Insurance? If Yes, Explain.
For CA Prospects Only: If self-employed, are you covered under the state disability insurance plan? If Yes, Explain.
OCCUPATION
Exact Occupational duties and % time spent on each duty: Occupation % spent
Occupation 1
Occupation 2
Occupation 3
Occupation 4
Number of people you supervise  
Length of time at current employer  
Are you self-employed? If Yes, Explain.
Are you a Federal, State, or City Employee? If Yes, Explain.
Do you work from your home? If Yes, Explain.
FINANCIAL
Gross Earnings (after expenses if self-employed)
Current Year to Date $  
Last Year $  
2 Years ago $  
Do you have annual unearned income (e.g.,dividens, interest) that exceeds 10% of earned income or does your net worth exceed $3,000,000? If Yes, Explain.
Did you receive any bonuses in the last 3 years? If Yes, Explain.