Client's Date of Birth*

Client's Sex*

Tobacco Use (All Nicotine Products)*

Is your client a government employee?*

Is your client self-employed?*

If your client is self-employed, how long?

Does Your Client Have Existing Coverage?*

(If Applicable) If your client's coverage is a group disability policy, who pays the premium?

Desired Elimination Period*

Desired Benefit Period*