Date of Birth:
01
02
03
04
05
06
07
08
09
10
11
12
01
02
03
04
05
06
07
08
09
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15
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20
21
22
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24
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28
29
30
31
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
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1983
1982
1981
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1974
1973
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1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
Gender:
Male
Female
Has the proposed insured ever used any form of tobacco or nicotine-based products, or substitutes such as patches or gum?
Yes
No
If "Yes", date of last use:
01
02
03
04
05
06
07
08
09
10
11
12
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
Is the proposed insured a United States citizen, or does the proposed insured have permanent (green card) status?
Yes
No
State of Residence:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist. of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Is the proposed insured self-employed?
Yes
No
Is the proposed insured a government employee?
Yes
No
Occupation Class: (
click here
to determine)
4A
3A
2A
1A
Not Eligible
Monthly Income:
(specify "gross" if not self-employed or "net" if self-employed)
Is the proposed insured currently working at least 30 hours per week in their primary occupation?
Yes
No
Monthly Disability Income Benefit:
(pre-filled with maximum benefit; you may input lower amount)
Need Advice?
Dave recommends choosing an amount equal to 60% to 70% of your monthly income which can be reduced based on your progress with debt and savings.
For more information click
https://www.zanderinsurancetips.com/2011/05/q-how-much-disability-insurance-should-i-have/
Benefit Period:
2 Years
5 Years
10 Years
To Age 65
Need Advice?
Dave recommends a minimum of at least a five year benefit period and longer if your budget can afford it.
For more information click
https://www.zanderinsurancetips.com/2011/05/q-what-benefits-should-i-look-for-in-a-long-term-disability-plan/
Elimination Period:
90 Days
180 Days
Need Advice?
Dave recommends taking the longest elimination period your budget and emergency fund can afford.
For more information click
https://www.zanderinsurancetips.com/2011/05/q-what-is-the-elimination-period-of-a-disability-policy/
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First Name:
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Last Name:
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Personal Phone Number:
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E-mail Address:
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not required