Start Disability Application

1
Name* This field is required.
Prefix
First Name
Middle Name
Last Name
Suffix
2
Birth Date* This field is required.
Month
Day
Year
3
Sex* This field is required.
Please Select
Please Select
Male
Female
N/A
4
Marital Status:* This field is required.
Single
Married
Other
5
E-mail* This field is required.
6
Phone* This field is required.
Area Code
Phone Number
7
Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
How long have you lived in your given address?* This field is required.
0-1 Year
1-2 Years
3-4 Years
5+ Years
9
Drivers License Information* This field is required.
Drivers License Number
License Expiration Date
State Issued
10
Are you a United States Citizen?* This field is required.
YESNO
11
Citizenship Information
What Country to you hold your citizenship through?
Visa Type
Visa #
Number of years residing in the United States
12
What State or Country were you born in?* This field is required.
13
Social Security Number* This field is required.
14
This years anticipated adjusted gross income* This field is required.
15
Last years adjusted gross income* This field is required.
16
2 years ago adjusted gross income* This field is required.
17
Have you ever filed for personal or business bankruptcy?* This field is required.
YESNO
18
Please provide details including bankruptcy discharge date
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19
Does your net worth exceed $4,000,000* This field is required.
YESNO
20
Net Worth Details
What is your total net worth
21
Employer Name* This field is required.
22
Employer Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
23
How long have you worked with the same employer* This field is required.
0-1 Year
1-2 Years
3-4 Years
5-9 Years
10+ Years
24
Occupation* This field is required.If you are a doctor - what is your medical specialty?
25
Occupation Duties* This field is required.Briefly describe what you do
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26
Do you work at least 30 hours per week?* This field is required.
YESNO
27
Are there more than 10 other people employed at the business where you work?* This field is required.
YESNO
28
Have you ever had a professional license suspended or revoked, or is such license currently under review?* This field is required.
YESNO
29
Please provide details
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30
Do you have any ownership in the business where you work?* This field is required.
YESNO
31
Business Ownership Questions
What Percentage of the business do you own?
Type of business: LLC, Partnership , S-Corp, C-Corp, Other
How many other owners/partners are there?
32
Do you participate in Group Long Term Disability Insurance provided through your employer?* This field is required.
YESNO
33
Group Disability Benefit Details
What percentage of your base income does your Employer Plan provide (50% or 60% of your base)
What is the monthly cap of your coverage (Example: 5,000 per month, 10,000 per month, 15,000 per month
Yes
No
Does your employer provide this plan to you for free?
34
Do you currently have individual disability insurance?* This field is required.
YESNO
35
Individual Disability Insurance Details
Who is your current carrier. If you have multiple carriers please list them all separated by commas.
What is your total monthly benefit from each carrier. If you have multiple carriers please list them all.
36
Are you replacing your existing individual disability insurance?
YESNO
37
Have you used tobacco or nicotine products in any form within the last 5 years?* This field is required.
YESNO
38
Please provide detailsProvide dates and type: cigarettes, cigarillos, cigars, pipe, chewing tobacco, nicotine patches, gum etc.
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39
Have you ever applied for insurance or reinstatement which has been: decline, postponed, rated, modified; or had any such insurance canceled or a renewal premium refused?* This field is required.
YESNO
40
Please provide detailsProvide date, reason, and company name.
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41
Have you ever received or claimed: Indemnity, benefits, or a payment for any injury, sickness or impaired condition?* This field is required.
YESNO
42
Please provide details
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43
Have you ever made any flights as: a pilot, student pilot, or crew member of any aircraft?* This field is required.
YESNO
44
Aviation Questions
Class of license certificate
Date of Issue
Date of Expiration of License if applicable. If not applicable simply answer N/A
Date of last FAA medical examination
Yes
No
Are you instrument Flight Rated
Student Pilot
Private Pilot
Commercial Pilot
Military Pilot
Crew Member
What type of pilot are you?
Date you last few as a pilot or crew member
Total solo flying hours
45
Do you fly or have any intention of flying outside the United States or Canada
YESNO
46
Please provide detailsProvide countries and dates
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47
Have you ever had an aircraft accident involving personal injuries or damage to any plane or property?
YESNO
48
Please provide detailsProvide countries and dates
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49
Has your license or certificate ever been suspended or have you been grounded for any violation or damage to any plane or property?
YESNO
50
Please provide detailsExplain fully providing dates and penalties imposed
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51
Are you a member of the Armed Forces, Active or Ready Reserve, Inactive or standby Reserve, or National Guard?
YESNO
52
Please provide details
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53
Provide the total hours below of all the flights you have made as a pilot or crew member during the past two years and your estimate of the flights contemplated within the next year. Answer "0" were applicable, as each item must be completed.
Last 12 Months
Last 24 Months
Next 12 Months
Scheduled Airline
Company-owned Plane
Nonscheduled Passenger or Cargo
Instructor, Charter Flying, Sight-Seeing, Photography, or Surveying
Testing, Forestry, Border Patrol or Crop Dusting
Active Military
Military Reserve or National Guard
As a Studen
Private Pilot
Experimental or Prototype Aircraft
Any other flying
Scheduled Airline
Company-owned Plane
Nonscheduled Passenger or Cargo
Instructor, Charter Flying, Sight-Seeing, Photography, or Surveying
Testing, Forestry, Border Patrol or Crop Dusting
Active Military
Military Reserve or National Guard
As a Studen
Private Pilot
Experimental or Prototype Aircraft
Any other flying
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
Last 12 Months
Last 24 Months
Next 12 Months
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54
In what type of aircraft do you fly?
55
Do you fly regularly?
YESNO
56
Please Provide Details
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57
Do you fly for proficiency only in connection with administrative duties?
YESNO
58
Please Explain
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59
Have you engaged in or do you contemplate engaging in any type of flying not already indicated?
YESNO
60
Please provide details
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61
Have you been convicted of a moving violation, had any traffic accidents, or had a driver's license revoked or suspended within the past five years?* This field is required.
YESNO
62
Please provide details
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63
Have you ever been charged with, or convicted of, or currently awaiting trial on the violation of any criminal law?* This field is required.
YESNO
64
Please provide details
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65
In the next year, do you have any intention of traveling outside the United States or Canada or residing outside of the United States?* This field is required.
YESNO
66
Please provide details
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67
Do you currently belong to or intent on joining any active or reserve military, naval, or aeronautic organization?* This field is required.
YESNO
68
Please provide details
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69
Do you engage in or plan to engage in any form of the following:* This field is required.
Motorized Racing
Marital Arts
Parachuting/Skydiving
Scuba Diving
Mountain Climbing
None of the above
70
How tall are you?* This field is required.
71
How much do you weight?* This field is required.
72
Has your weight changed by more than 10 lbs. in the last twelve months?* This field is required.
YESNO
73
How much weight have you gained or lost and what was the reason for your weight change?
74
Have you ever been medically evaluated for, diagnosed with or treated for any of the following:* This field is required.
Yes or No
If Yes, Please provide Details
High Blood Pressure?
Yes
No
High Cholesterol?
Yes
No
Disorder of your eyes, ears, nose or throat?
Yes
No
Dizziness, vertigo, fainting, seizures, recurrent headache; speech defect, tremor, neuropathy, paralysis, multiple sclerosis, stroke, transient ischemic attack (TIA), memory loss, dementia, or any other disorder of the brain or nervous system?
Yes
No
Shortness of breath, chronic cough, bronchitis, asthma, emphysema, chronic obstructive pulmonary disease (COPD), sleep apnea, or chronic respiratory disorder?
Yes
No
Chest pain, irregular heartbeat, heart murmur, heart valve disease, heart attack, coronary artery disease, heart failure, aneurysm or other disorder of the hear of blood vessels?
Yes
No
Intestinal bleeding, inflammatory bowel disease (including Crohn's disease or ulcerative colitis), hepatitis, diverticulitis, recurrent indigestion or other disorder of the esophagus, stomach, intestines, pancreas, liver or gallbladder?
Yes
No
Sugar, protein, or blood in the urine, sexually transmitted disease (excluding HIV); chronic kidney disease, kidney stone or other disorder of the kidneys or bladder?
Yes
No
Diabetes, elevated blood sugar thyroid, pituitary, adrenal or other endocrine (glandular) disorders?
Yes
No
C-section, miscarriage, or complication of pregnancy?
Yes
No
Arthritis, gout, lupus or disorder or injury to the bones, muscles, wrists, hips, knees or other joints?
Yes
No
Spinal, neck or back disorder or injury, including sprains, strains, or dis disorder?
Yes
No
Mass, polyp, cyst, tumor or cancer?
Yes
No
Allergies; disorder of the skin; anemia, bleeding, clotting or other disorder of the blood?
Yes
No
Anxiety, depression, stress, attention deficit hyperactivity disorder (ADHD), eating disorder or other psychiatric or mental health disorder?
Yes
No
Chronic fatigue, chronic pain, fibromyalgia, or fever of unknown cause?
Yes
No
Are you currently pregnant?
Yes
No
Have you been diagnosed by a licensed medical professional as having Acquired Immune Deficiency Syndrome (AIDS) or ever tested positive for Human Immunodeficiency Virus (HIV)?
Yes
No
High Blood Pressure?
High Cholesterol?
Disorder of your eyes, ears, nose or throat?
Dizziness, vertigo, fainting, seizures, recurrent headache; speech defect, tremor, neuropathy, paralysis, multiple sclerosis, stroke, transient ischemic attack (TIA), memory loss, dementia, or any other disorder of the brain or nervous system?
Shortness of breath, chronic cough, bronchitis, asthma, emphysema, chronic obstructive pulmonary disease (COPD), sleep apnea, or chronic respiratory disorder?
Chest pain, irregular heartbeat, heart murmur, heart valve disease, heart attack, coronary artery disease, heart failure, aneurysm or other disorder of the hear of blood vessels?
Intestinal bleeding, inflammatory bowel disease (including Crohn's disease or ulcerative colitis), hepatitis, diverticulitis, recurrent indigestion or other disorder of the esophagus, stomach, intestines, pancreas, liver or gallbladder?
Sugar, protein, or blood in the urine, sexually transmitted disease (excluding HIV); chronic kidney disease, kidney stone or other disorder of the kidneys or bladder?
Diabetes, elevated blood sugar thyroid, pituitary, adrenal or other endocrine (glandular) disorders?
C-section, miscarriage, or complication of pregnancy?
Arthritis, gout, lupus or disorder or injury to the bones, muscles, wrists, hips, knees or other joints?
Spinal, neck or back disorder or injury, including sprains, strains, or dis disorder?
Mass, polyp, cyst, tumor or cancer?
Allergies; disorder of the skin; anemia, bleeding, clotting or other disorder of the blood?
Anxiety, depression, stress, attention deficit hyperactivity disorder (ADHD), eating disorder or other psychiatric or mental health disorder?
Chronic fatigue, chronic pain, fibromyalgia, or fever of unknown cause?
Are you currently pregnant?
Have you been diagnosed by a licensed medical professional as having Acquired Immune Deficiency Syndrome (AIDS) or ever tested positive for Human Immunodeficiency Virus (HIV)?
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
Yes or No
Yes
No
If Yes, Please provide Details
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75
Within the past 5 years have you* This field is required.
Yes or No
If Yes, Please provide details
Consulted or received treatment from a chiropractor?
Yes
No
Had a checkup, consultation, illness, injury, or surgery; been a patient in a hospital, rehabilitation center or other medical facility; had an X-ray, EKG, heart scan, MRI or CT scan, biopsy or other diagnostic test (excluding HIV)?
Yes
No
Been advised by a licensed medical professional to have any diagnostic test (excluding HIV), hospitalization, or surgery which has not been completed?
Yes
No
Consulted or received treatment from a chiropractor?
Had a checkup, consultation, illness, injury, or surgery; been a patient in a hospital, rehabilitation center or other medical facility; had an X-ray, EKG, heart scan, MRI or CT scan, biopsy or other diagnostic test (excluding HIV)?
Been advised by a licensed medical professional to have any diagnostic test (excluding HIV), hospitalization, or surgery which has not been completed?
Yes or No
Yes
No
If Yes, Please provide details
Yes or No
Yes
No
If Yes, Please provide details
Yes or No
Yes
No
If Yes, Please provide details
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76
Within the past 10 years have you* This field is required.
Yes or No
If Yes, Please Provide Details
Used marijuana, cocaine, heroin, barbiturates, tranquilizers, hallucinogens, amphetamines, narcotics or any other drug, except as legally prescribed by a doctor?
Yes
No
Sought, received or been advised to seek medical treatment or counseling for the use of alcohol or drugs?
Yes
No
Consumed alcoholic beverages? If yes, please specify the extent of your use.
Yes
No
Used marijuana, cocaine, heroin, barbiturates, tranquilizers, hallucinogens, amphetamines, narcotics or any other drug, except as legally prescribed by a doctor?
Sought, received or been advised to seek medical treatment or counseling for the use of alcohol or drugs?
Consumed alcoholic beverages? If yes, please specify the extent of your use.
Yes or No
Yes
No
If Yes, Please Provide Details
Yes or No
Yes
No
If Yes, Please Provide Details
Yes or No
Yes
No
If Yes, Please Provide Details
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77
Are you currently taking any prescription or nonprescription medications?* This field is required.
YESNO
78
Please provide the details of your medicationsPlease list the medication name, dosage, usage, the reason for using the medication and the name of the physician that prescribes it to you
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79
Family Health History* This field is required.Have you or your immediate family members (parents, brothers and sisters) died of or been diagnosed as having coronary artery disease, stroke, diabetes, cancer, polycystic kidney disease or Huntington's disease prior to age 60?
YESNO
80
Please provide details
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81
Family History* This field is required.
Yes or No
If Yes, How Old
If No, cause of death and age of death
Is your Father still living?
Yes
No
N/A
Unknown
Is your Mother Still Living
Yes
No
N/A
Unknown
Are all your Brothers still living
Yes
No
N/A
Unknown
Are all your Sisters still living
Yes
No
N/A
Unknown
Is your Father still living?
Is your Mother Still Living
Are all your Brothers still living
Are all your Sisters still living
Yes or No
Yes
No
N/A
Unknown
If Yes, How Old
If No, cause of death and age of death
Yes or No
Yes
No
N/A
Unknown
If Yes, How Old
If No, cause of death and age of death
Yes or No
Yes
No
N/A
Unknown
If Yes, How Old
If No, cause of death and age of death
Yes or No
Yes
No
N/A
Unknown
If Yes, How Old
If No, cause of death and age of death
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82
Within the past 5 years have you had a visit with a Primary Care Physician or any health provider?* This field is required.
YESNO
83
Personal or Attending Physician Information
Name or names of you personal physicians
Date last consulted
Reason for your visit and was any medication/treatment provided
Full address and phone number of your personal physicians
84
Do you prefer to pay your premiums monthly or annually?* This field is required.Most clients choose monthly
Monthly
Annually
85
Electronic Funds Transfer InformationYour Payment information is kept on file until your policy is approved. Once your policy is approved the insurance carrier will not draft your payment until InsuranceMD has received your approval.
Name of Bank for which you want to pay your premiums from
9 Digit Routing Number
Checking Account Number
86
Electronic Signature and Delivery Disclosures* This field is required.You are not required to sign electronically. If you prefer to consent to use electronic transactions, simply check the "YES" option below. To decline your consent to use electronic transactions, simply choose the "NO" button below. If you decline your consent, a paper copy of your application and other policy documents will be mailed or provided by your agent without charge to you for your written signature.
YESNO
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Insurance Application AgreementApplication for Insurance: Notice of Insurance Information Practices: To issue an insurance policy we need to obtain information about you and any other persons proposed for insurance. Some of that information will come from you and some will come from other sources. We may obtain information relating to any proposed insured's mental and physical health, general character and reputation, habits, finances, occupation, other insurance coverage, or participation in hazardous activities. This information may be obtained from physicians, medical professionals, hospitals, clinics or other medical care institutions, or from MIB, Inc. ("MIB"), public records, consumer reporting agencies, financial sources, other insurance companies, agents, friends, neighbors and associates. We may obtain information through exchanges or correspondence, by telephone or by personal contact. Information regarding your insurability or claims will be treated as confidential. The Company or its reinsurers may, however, make a brief report thereon to MIB, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you, the MIB will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB's file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184- 8734; telephone number (866) 692-6901 (TTY 866-346-3642); website address www.mib.com. The Company or its reinsurers may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Furthermore, as part of our procedure for processing your insurance application, an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends, associates, or others with whom you are acquainted. This inquiry and any subsequent investigative consumer report update which may also be requested includes information as to your character, general reputation, personal characteristics, and mode of living. You have the right to be personally interviewed if we order an investigative consumer report. Please notify our agent if this is your wish. You are also entitled to receive a copy of the investigative consumer report whether or not an interview is conducted. You also have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigation. To reduce costs and offer insurance coverage at the lowest possible premium, the Company may also use a Personal History Interview. A specially trained interviewer may call to discuss information contained in your application or to ask questions related to the underwriting of your insurance. We will attempt to conduct this telephone interview at your convenience and at a number you designate. In the event of an adverse underwriting decision, upon written request, we will provide you with the specific reason in writing for that adverse underwriting decision. As a general practice, we will not disclose personal information about you to anyone else without your consent, unless a legitimate business need exists or disclosure is required or permitted by law. A description of the circumstances under which information about you might be disclosed without your authorization will be sent to you upon request. You have a right of access to personal information we maintain in our files and to request correction, amendment, or deletion of any information you believe to be incorrect. You may request a description of established procedures which will allow access to and correction of such personal information. If you wish to have a more detailed explanation of our information practices, including your rights of access to and correction of personal information, please contact the Underwriting Department at the above address. Agreement: The undersigned represent that their statements in this application and Part II, if such Part II is required by the Company, are true and complete to the best of their knowledge and belief. It is agreed that: (a) the only statements to be considered as the basis of the policy are those contained in the application or in any amendment to the application; (b) any prepayment made with this application will be subject to the provisions of the TEMPORARY INSURANCE AGREEMENT; (c) if there is no prepayment made with this application, the policy will not take effect until: (1) the first premium is paid during the lifetime of the proposed insured(s) and while his/her health and the facts and other conditions affecting their insurability remain as described in this application and Part II, if required; and (2) the policy is delivered to the Owner; (d) no one except the President, a Vice President, the Secretary, or an Assistant Secretary can make, alter or discharge contracts or waive the Company's rights or requirements; and (e) this application was signed and dated in the state indicated. The agent certifies that the information was truly and accurately recorded on this application. If applying for an indeterminate premium plan: (a) the premium for such plan is guaranteed for the initial guarantee period, and after such period, the current annual premium is not guaranteed and may change; and (b) the premium will never exceed the specified maximum. Fraud Notice Any person who knowingly or with intent to defraud; submits an application or files a claim containing false, incomplete or misleading information; is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim.
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Application for Insurance AuthorizationI authorize any health care providers, pharmacy benefit manager, hospitals, insurers, consumer reporting agency, government agency, financial institution, and/or accounting, educational institution, or employer; having data or facts about the proposed insured's or claimant's physical or mental condition, medical care, advice, treatment, use of drugs, alcohol or tobacco, HIV, AIDS and sexually transmitted diseases, prescription drug records, financial status, education records, or employment status or other relevant data or facts about the proposed insured or claimant; including wage and earnings, or data or facts with respect to other insurance coverage; to give all data or facts to the Company, its reinsurers, or any other agent or agency acting on the Company's behalf. I authorize MIB, Inc., and any MIB member insurer, to provide any medical or personal information that it has about me to the Company, its reinsurers or any MIB-authorized third-party administrator performing underwriting services on the Company's behalf. I also authorize the Company, its reinsurers or authorized third-party administrator, to make a brief report of my protected health information to MIB, Inc. I authorize any physician, health care professional, hospital, clinic, medical facility, other health care provider or health plan, insurer, or other covered entity subject to HIPAA, to release and disclose my medical record without restriction pursuant to 45 CFR 164.524. I understand that my personal information, including my protected health information disclosed under this authorization, will be incorporated into and made a part of any life and/or disability income insurance policy(s) issued by the Company in connection with the application(s) for insurance that I have submitted to the Company. I further understand that the policy(s) will be delivered to the policy owner, which may be my employer or other party. The information included and forming a part of such policy(s), including my protected health information, may be disclosed to the policy owner. I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization to disclose. I understand any information disclosed under this authorization may no longer be covered by the privacy provisions of HIPAA and may be subject to re-disclosure. 45 CFR 164.508(c)(2)(ii). I understand I do not have to sign this authorization in order to obtain health care (treatment, payment, enrollment or eligibility for benefits). 45 CFR 164.508(c)(2)(ii).). My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or my eligibility for health benefits. 45 CFR 164.508(c)(2)(ii). I acknowledge and agree that the above data and facts will be used to: (1) underwrite an application for coverage; (2) obtain reinsurance; (3) resolve or contest any issues of incomplete, incorrect, or misrepresented information on the application identified above which may arise during the processing or review of the application, or any other application for insurance; (4) administer coverage and claims; and (5) complete a consumer report, investigative consumer report or telephone interview about the proposed insured or claimant. I may request to be interviewed in connection with the preparation of the investigative consumer report and am entitled to receive a copy of that report. I agree that this authorization is valid for such time limit, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery. I also agree that a copy is as valid as the original. I, or my authorized representative, am entitled to a copy. For purposes of collecting data or facts relating to a claim for benefits, this authorization is valid for the duration of the claim. I understand that: (1) I can revoke this authorization at any time by giving written request to the Company; (2) revoking this authorization will not affect any prior action taken by the Company in reliance upon this authorization; and (3) failing to sign, or revoking this authorization may impair the Company's ability to process my application or evaluate my claim and may be a basis for denying this application or a claim for benefits. I acknowledge receipt of Notice of Insurance Information Practices.
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Notice and Consent Form for Testing Which May Include AIDS Virus (HIV) Antibody/Antigen TestingTo determine your insurability, the Insurer has requested that you provide a sample of your body fluids for testing and analysis. All tests will be performed by a licensed laboratory. Tests will be performed to determine the presence of HIV antibodies or antigens to the Human Immunodeficiency Virus (HIV) also known as the AIDS virus. The HIV antibody test that we perform is actually a series of tests done by a medically accepted procedure. The HIV antigen test directly identifies AIDS viral particles. These tests are extremely accurate. Other tests which may be performed include determinations of cholesterol and related lipids (fats), and screening for liver and kidney disorders, diabetes and immune disorders. All test results will be treated confidentially. They will be reported by the laboratory to the Insurer. When necessary for business reasons in connection with insurance you have or have applied for with the Insurer, the Insurer may disclose test results to others involved in the underwriting and claims review process. If the HIV test is positive, the results will be reported to the local health department or the State Department of Health, and if the Insurer is a member of MIB, Inc. ("MIB"), the Insurer may report the results in a generic code which signifies only a non-specific test abnormality. If your HIV test is normal, no report will be made about it to MIB. Other test results may be reported to MIB in a more specific manner. The organizations described in this paragraph may maintain the test results in a file or data bank. There will be no other disclosure of test results or even that the tests have been done except as may be required or permitted by law or as authorized by you. If your HIV test results are normal, no routine notification will be sent to you. If the HIV test results are other than normal, the Insurer, your designated physician or your local Health Department will contact you. The Insurer may also contact you if there are other abnormal test results which, in the Insurer's opinion, are significant. The Insurer may ask you for the name of a physician or other health care provider to whom you may authorize disclosure and with whom you may wish to discuss the results. Positive HIV antibody/antigen test results do not mean that you have AIDS, but that you are at significantly increased risk of developing AIDS or AIDS-related conditions. Federal authorities say that persons who are HIV antibody/antigen positive should be considered infected with the AIDS virus and capable of infecting others. Positive HIV antibody or antigen test results or other significant blood abnormalities will adversely affect your application for insurance. This means that your application may be declined, that an increased premium may be charged, or that other policy changes may be necessary. In the event of a positive HIV test result, I authorize the Insurer to send test results to the following physician or health care provider for post-test counseling and for Health Department reporting purposes:
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Electronic Funds Transfer (EFT) ** For Variable Life contracts, a copy of a Pre-printed Voided Check is required. In some other circumstances we will require a copy of a pre-printed, voided check or a letter from the bank indicating the ABA Routing Number, Account Number, and the Account Holder's Name for verification. IT IS UNDERSTOOD THAT: Either or both of the above arrangements may be terminated by the Policy Owner or by the Company upon written notice. If the Bank Account Holder ("Payor") is other than the Policy Owner, the Company will terminate either or both of the arrangements upon written request of such Payor. Should the Premiums cease to be paid by Electronic Payment, the Company will accept payment of quarterly, semiannual or annual premium payments at the Company's published rates in effect as of the date of the policy. For Policies Earning Dividends: Dividends cannot be used to offset Electronic Premium Payments. If dividends are currently being used to reduce premiums, please submit a dividend change form (UN 3379 B). As a convenience to me (Payor and undersigned), I hereby request and authorize the Company, to pay and charge to my account checks, drafts or orders, whether by electronic or paper means, drawn on my account by the Company to its own order. This authorization will remain in effect until revoked by me in writing, and until the Company actually receives such notice I agree that the Company shall be fully protected in honoring any such order. I (Payor and undersigned) understand that premium payments are necessary to fund the policy. If my financial institution does not honor a withdrawal, I may be required to send the Company a replacement payment. If the Company does not receive a replacement payment within the time required, the policy may enter its grace period and then lapse. Once a policy lapses, it no longer offers life insurance coverage. The bank shall be under no obligation to furnish me (Payor and undersigned) with any special advice or notice in writing or otherwise of the payment and charge of such checks, drafts, or orders to my account. Declaration: By signing this form I certify that I am an authorized signature for the bank account listed above.
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Electronic Signature AgreementYou have the right to revoke your consent to use electronic transactions or notify the Company of any updated information by contacting the Company at the address or phone number listed above. Your consent will be effective until you revoke it. If you withdraw your consent, it will not affect the legal standing of any signed documents you may have previously submitted. , If you accept electronic delivery, you will always have the option of printing a copy of your completed electronic policy pages using your own printer. , This disclosure covers all electronic policy pages arising out of an application for life or disability income insurance coverage through the Company. When signing documents electronically in lieu of a paper-based signature, you acknowledge your understanding that electronic signatures are legally binding in the United States and in other countries. You further represent that you have read the documents to be submitted electronically and that they have been accurately filled out. . If you consent to the use of an electronic signature to sign and receive Company electronic policy pages at your valid email address, sign below. The receipt of your electronically signed policy pages by the Company will demonstrate that you can access the electronic forms provided to you. • I had dialogue with the agent and I understand precisely the intentions of the electronic signature and I have, when applicable, visual confirmation of the actual electronic signing process. • I understand there will be automatic encryption and storage of my signature. • I understand that I will be given a 4 digit access code to access and electronically sign my documents via DocuSign.
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Understanding of Next Steps* This field is required.This is not a formal application. If you elected to sign your application electronically, within in the next 24 business hours you will receive an email from your InsuranceMD agent which contains a link from your insurance carrier where you will be asked to re-review the information you have submitted on this online preliminary application and be asked to electronically sign the documents again from the insurance carrier you are applying from. Upon receiving your signature link, you will have 24 hours to complete your signature. You will receive a 2nd email from InsuranceMD providing you access to your secure client portal. Your portal will contain a copy of your completed application, applied for illustrations, along with a "To-Do" list of items that are required for you to complete and/or upload to finalize your underwriting application. If you opted out of electronic signature you will receive a PDF document from your InsuranceMD agent within the next 24 business hours. From here you will be asked to print, sign, and return to us in a manner in which you are comfortable your completed and signed application. If you have any questions, please contact us directly at 800-538-3767. Please sign below to acknowledge your understanding of the next steps involved in finalizing your application.
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