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Disability Pre-Qualification Form

Home/Disability Pre-Qualification Form

Disability Pre-Qualification Form

Disability Insurance Pre-Qualification

Name of referring Agent?(Required)

Referring Agent's Phone Number:(Required)

Referring Agent's Email Address:(Required)

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

State of Residency(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Height(Required)

Weight(Required)

Gender(Required)

Annual Income(Required)

Do you recieve any passive income such as rental income, capital gains, royalties, or dividends? (Yes/No)(Required)

Have you previously been declined for insurance coverage (Yes/No)(Required)

Which product type?

Life Insurance

Disability Insurance

Long Term Care

Reason for Decline?

Have you ever used tobacco? (Yes/No)(Required)

Which type have you used/are currently using? (please select all that apply)

Cigarettes

Cigars

Chewing Tobacco

Vapes

Other

Are you currently using tobacco? (Yes/No)(Required)

If no, what is the date of last usage?

MM slash DD slash YYYY

Have you used marijuana in the last 12 months? (Yes/No)(Required)

If yes, how are you taking them?

Smoke

Edibles

Other

If yes, the date of your last usage?

MM slash DD slash YYYY

Is it a prescription? (Yes/No)

Do you have a history of any of the below options? (please select all that apply)(Required)

Cancer

Diabetes

Sleep Apnea

Coronary Artery Disease

Neck or Back Disorder

Depression and/or Anxiety

Immune Systems Disorders

Balance or Gait Impairment

Surgery or Medical Procedures (in the last 10 years)

Scheduled Procedures, Tests, or Surgeries not completed at this time

Any other medical concerns not listed above

None of the Above

Type of Cancer and date of completion?

Type of diabetes, date of diagnosis, and last known AC1 and reading?

Date of onset?

MM slash DD slash YYYY

Severity of Sleep Apnea? (please choose one)

Mild

Moderate

Severe

Have you been prescribed a Cpap to use? (Yes/No)(Required)

If yes, are you currently using the Cpap machine?

Date of Diagnosis

MM slash DD slash YYYY

Any surgical procedures? (Yes/No)

If yes, Date or procedure?

MM slash DD slash YYYY

Date of last Cardiac test?

MM slash DD slash YYYY

Type of Surgery or Medical Procedure:

Date of procedure:

MM slash DD slash YYYY

Outcome of procedure:

Types of medical concerns not covered from above: (list here)

Diagnosis Date:

MM slash DD slash YYYY

Date of your last treatment?

MM slash DD slash YYYY

Have you had a physical check up with your health care provider in the last 2 years?(Required)

If yes, approximate date:

MM slash DD slash YYYY

In the last 5 years have you seen a Chiropractor?(Required)

If yes, reason for the visit?

Last date of appointment:

MM slash DD slash YYYY

In the last 5 years have you seen a counselor/psychiatrist?(Required)

If yes, last date seen:

MM slash DD slash YYYY

Any prescription medications taken during the past 2 years?(Required)

If yes, please list the medication(s) below- Name of Medication, dose of Medication, and reason your were prescribed:

Have you ever been diagnosed to be genetically predisposed or carry a gene that could develop diseases such as Cancer, Coronary artery disease, or Alzheimer's?(Required)

Do you particiapte in any of the following? (please select all of the following that apply)(Required)

Scuba Diving

Sky Diving

Bungee Jumping

Rock Climbing

Racing

Other

None of the Above

Type of Occupation:(Required)

Years in field of Occupation:(Required)

Are you Employed Full-Time?(Required)

Employer's Name:

Years Employed:

How many hours per week do you work?(Required)

Do you supervise employees?

If yes, how many?

Do you own your own business?(Required)

Type of business:

What is your percentage of ownership?

Total Number of employees:

Are you employed part time?(Required)

Employer's Name:

Years of Employment:

How many hours per week do you work?(Required)

Do you supervise employees?

If yes, how many employees:

Do you have any other Disability Insurance? (Yes/No)(Required)

If yes, Select the one(s) you have: (please select all that apply):

Individual

Group

Association

What is the Monthly Benefit and Are you going to replace this?

What is the Monthly Benefit and Are you going to replace this?

What is the Monthly Benefit and Are you going to replace this?

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About Us

Headquartered in Elkhorn, Nebraska, OCI Insurance & Financial Services, Inc., is an insurance general agency providing support to thousands of agents nationwide in the placement of these products and services.

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