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Client's Date of Birth
Month
Day
Year
Client's Sex
Tobacco Use (All Nicotine Products)
Is your client a government employee?
Is your client self-employed?
Yes
No
If your client is self-employed, how long?
Less than one year
Less than two years
2+ Years
Does Your Client Have Existing Coverage?
Yes
No
(If Applicable) If your client's coverage is a group disability policy, who pays the premium?
Employer
Employee/Individual
Desired Elimination Period
30 Days
60 Days
90 Days
180 Days
365 Days
730 Days
Desired Benefit Period
2 Years
5 Years
10 Years
To Age 65
To Age 67
To Age 70
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