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Disability Questionnaire SECTION I: AGENT INFORMATION * Full Name of Agent Address Line 1 Address Line 2 City, State, Zip * E-Mail * Business Phone Cell Phone Home Number Fax Number SECTION II: APPLICANT INFORMATION Applicants Name: Date of Birth Sex: Male Female Resident State: State written: Does the applicant use tobacco?: None Cigarette Cigar Chew Occupation (If not currently employed, explain i.e. Retired, Disabled, Social Security Disability, Workmans Comp) Specific Job Duties: Annual income: Self-Employed? Yes No Any existing individual or group coverage? Yes No If yes, please provide details of coverage: Who will be paying for the coverage? Individual Employer SECTION III: BENEFIT INFORMATION Type of coverage? Individual Coverage Business Overhead Expense Business Disability Buy-Out Insurance Monthly benefit: Elimination Period 30 Days 60 Days 90 Days 180 Days 365 Days 730 Days Benefit Period 2 Years 5 Years Age 65 Riders Residual (Partial Earning Loss) Future Purchase Options C.O.L.A. Non-Cancelable Own Occupation Social Insurance SECTION IV: CASE INFORMATION Are you in competition for this case? Yes No I don't know If yes, please specify: Additional comments? Any health concerns? Known medications?