Short-Term Disability Insurance Application




Do you work at least 30 hours per week in this occupation?

How many years have you worked in this occupation?


Are you a government employee?

If yes, please select if you’re a federal, state or local government employee.


Percentage of time you work at home:

Corporate Structure:

Are you self-employed or a business owner?

If yes, please let us know the following:

Ownership stake (0-100%):

Number of partners or co-owners:

Number of employees:

Year Company Founded:

Became Owner/Partner in:

Highest Level of Education:

Individual annual income:

Do you have an existing disability insurance plan?

If yes, please let us know the following:

Existing Coverage:

Type of disability coverage you have:

Do you intend on replacing existing coverage?