Short-Term Disability Insurance Application
Pre-existing conditions are not covered by Short-Term Disability insurance.
Any health issue you’ve had, or currently have, will be excluded from the cover.
For example, if you have diabetes, any diabetes-related claims will not be paid by the insurer.
Your Weight (lbs):
Your Height (ft):
Please confirm the following:
Have you ever used a tobacco product?
Has your license been revoked or suspended in the last 10 years?
Have you ever been convicted of drunk driving (DUI/DWI) in the last 10 years?
Other serious medical conditions:
Have you ever seen a doctor, or been diagnosed with any of the following conditions?
(select all that apply)