Short-Term Disability Insurance Application

Pre-Existing Conditions

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Has your license been revoked or suspended in the last 10 years?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)