Financial Solutions – Disability PreQualification Form

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Disability Insurance Pre-Qualification

Thank you for the opportunity to assist you with your Disability planning needs. If you complete this form, we will use the information to submit a preliminary assessment with the Disability providers to determine potential eligibility and estimated rates.

Is your household income under $80,000?

Yes

Please complete this form on the Assurity Disability website.

Agent Info

Name of Agent?(Required)

Agent's Phone Number:(Required)

Agent's Email Address:(Required)

Applicant Information

Applicant Name(Required)

First Last

Applicant Phone Number(Required)

Applicant Address(Required)

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

Applicant Email(Required)

State of Residency(Required)

Date of Birth(Required)

Height(Required)

Weight(Required)

Gender(Required)

Male

Female

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?

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?

Is it a prescription? (Yes/No)

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

What type of Cancer were you diagnosed with?

What is the date treatment was completed?

What type of Diabetes were you diagnosed with?

When were you diagnosed?

What was your last known A1C reading?

Date of onset?

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

Any surgical procedures? (Yes/No)

If yes, Date or procedure?

Date of last Cardiac test?

Type of Surgery or Medical Procedure:

Date of procedure:

Do you recieve more than 2 injections a year for your neck or back?

Have you had 2 or more prior back surgeries with ongoing chronic/recurrent back pain requiring treatment?

If yes, what type of procedure?

Outcome of procedure:

What was the date of procedure?

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

Diagnosis Date:

Date of your last treatment?

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

If yes, approximate date:

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

If yes, reason for the visit?

Last date of appointment:

Have you been hospitalized in the last 5 years for depression?

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

If yes, last date seen:

What is the name of your immune system disease?

What date were you diagnosed?

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

If yes, what type?

What was the date of last treatment?

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

Are you a Doctor or In your Residency?(Required)

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?

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