Individual Disability Individual Disability Individual Disability Full Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Information About You & Your SpousePlease enter information below for all to be coveredYour InformationDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedOccupationHeightWeightSmokerYesNoHave you had any of the following health conditions None Heart Cancer Diabetes HBP Spouse InformationName First Last Date of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedOccupationHeightWeightSmokerYesNoHave you had any of the following health conditions None Heart Cancer Diabetes HBP Medical BackgroundHave you used any form of tobacco products? (cigarettes, pipe, chew, nicotine gum or patches)Past 36 Months?YesNoPast 60 Months?YesNoHave you ever been rated or declined for life insurance?YesNoIf Yes, Why?Have you ever been treated for high blood pressure or cholesterol?YesNoHas any member of your family (parent or sibling) died from coronary artery disease prior to age 60?YesNoIs there a family history of colon or prostate cancer (for male applicant) or breast, ovarian, or colon cancer (female applicant) in a parent or sibling prior to age 60?YesNoAre you currently taking or have you been advised to take any prescription medications?YesNoIf Yes, Why?Have you had a DUI / reckless driving conviction in past 5 years or 3 moving violations in the past 3 years?YesNoLife CoveragesCoverage for SelfAmount of Coverage ($)Type of CoverageTermWholeUniversalDisability IncomeYesNoLong Term CareYesNoCoverage for SpouseAmount of Coverage ($)Type of CoverageTermWholeUniversalDisability IncomeYesNoLong Term CareYesNoFinal Questions/CommentsComments / Remarks
