First Name:
Last Name:
Phone Number:
Email Address:
Citizenship:	U.S. Citizen Permanent Resident (Green Card) Other Select from menu
State of Residence:
Date of Birth:
Sex:	Male Female Select from menu
Risk Class:	Great Health Good Health Average Health Poor Health Select from menu
Occupation & Duties:	Please list your occupation and the duties of your occupation.
Employment:	Self-Employed Not Self-Employed Select from menu
Monthly Income: (Specify monthly income as Net if self-employed; Gross if not self-employed)
Number of hours employed per week:
Monthly Benefit: (The Monthly Benefit is the amount of monthly income you receive while disabled.  Please note that the typical maximum amount of Monthly Benefit is 60% of your income)
Benefit Period: (The Benefit Period refers to length of time your disability income will be paid to you.  We suggest 5 years or to age 65)	2 Years 5 Years To age 65 Select from menu
Elimination Period: (The elimination period is the time you wait from when you become disabled to when your benefit starts to pay you.  We suggest 90 days)	90 Days 180 Days Select from menu