Name:
PGY: 12345
DOB:
D
M
Y
Sex: MaleFemale
Medical Specialty:
Do you have future employment established?: YesNo
Employer:
Employment Start Date:
State:
Base Salary:
Bonus:
Medical Occupation:
In the past 60 months, have you been declined or postponed for disability insurance?: YesNo
If yes, why?
Any existing group or individual disability insurance?
Monthly Cap:
Percentage:
During the past 90 days, including the date of this application, have you missed work, altered your work schedule or location, worked less than a full-time schedule, or had to limit any of your duties, due to sickness or injury? YesNo
In the past 10 years, have you been diagnosed with or treated by a medical professional for a condition related to the loss of: speech; or hearing in both ears; or sight in both eyes; or use of both hands, both feet, or one hand and one foot? YesNo
Do you need human assistance of any kind or the use of adaptive equipment (such as: wheelchair, oxygen tank, cane, catheter, artificial limb, etc.) to perform everyday activities (such as: bathing; dressing; continence; eating; using the toilet; or transferring, for example, from a chair to a bed)? YesNo
In the past 10 years, have you received treatment or advice from a medical professional for memory loss, confusion, or loss of speech or comprehension of spoken language resulting from an injury or from a sickness (such as Alzheimer’s disease, stroke, senility, dementia, etc.)? YesNo
If yes to any of the above, please explain (description of diagnosis, duration, dates, treatment, etc.):
