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Disability Insurance Questionnaire-2
Broker Name
Broker Phone
Email
Resident State
Client Name
Date of Birth
MM slash DD slash YYYY
Male/Female
Male
Female
Occupation
Daily Duties & Responsibilities
Self-Employed?
Yes
No
If yes, how many years?
How many employees?
Years in this Occupation
Years with Current Employer
Work from home office
Government Employee?
Yes
No
% of Time in Home
Existing Group DI Benefits
Individual DI Benefits
Annual Income - Current
Annual Income - Last
Annual Income - Two Years Ago
Medical History: (Neck, Back, Mental/Nervous, Blood Pressure etc.)
Medications
Height
Weight
Tobacco User?
Yes
No
Coverage Type
Individual
Overhead Expense
Buy Out
Monthly Benefit Desired
Benefit Duartion
Optional Riders:
Residual/Partial Disability
True Own Occupation
Guaranteed Non Can
Future Purchase Option
COLA
Multi Life Discount (3 employees)