Disability Pre-Qualification Form

Disability Insurance Pre-Qualification

Thank you for the opportunity to assist you with your Disability planning needs. If you complete this form, we will use the information to submit a preliminary assessment with the Disability providers to determine potential eligibility and estimated rates.

Is your income under $80,000?

Yes

Please complete this form on the Assurity Disability website.

Agent Info

Name of Agent?(Required)

Agent's Phone Number:(Required)

Agent's Email Address:(Required)

Applicant Information

Applicant Name(Required)

First Last

Applicant Phone Number(Required)

Applicant Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicant Email(Required)

State of Residency(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Height(Required)

Weight(Required)

Gender(Required)

Male

Female

Annual Income(Required)

Do you receive any passive income such as rental income, capital gains, royalties, or dividends? (Yes/No)(Required)

Have you previously been declined for insurance coverage (Yes/No)(Required)

Which product type?

Life Insurance

Disability Insurance

Long Term Care

Reason for Decline?

Have you ever used tobacco? (Yes/No)(Required)

Which type have you used/are currently using? (please select all that apply)

Cigarettes

Cigars

Chewing Tobacco

Vapes

Other

Are you currently using tobacco? (Yes/No)(Required)

If no, what is the date of last usage?

MM slash DD slash YYYY

Have you used marijuana in the last 12 months? (Yes/No)(Required)

If yes, how are you taking them?

Smoke

Edibles

Other

If yes, the date of your last usage?

MM slash DD slash YYYY

Is it a prescription? (Yes/No)

Do you have a history of any of the below options? (please select all that apply)(Required)

Cancer

Diabetes

Sleep Apnea

Coronary Artery Disease

Neck or Back Disorder

Depression and/or Anxiety

Immune Systems Disorders

Balance or Gait Impairment

Surgery or Medical Procedures (in the last 10 years)

Scheduled Procedures, Tests, or Surgeries not completed at this time

Any other medical concerns not listed above

None of the Above

What type of Cancer were you diagnosed with?

What is the date treatment was completed?

MM slash DD slash YYYY

What type of Diabetes were you diagnosed with?

When were you diagnosed?

MM slash DD slash YYYY

What was your last known A1C reading?

Date of onset?

MM slash DD slash YYYY

Severity of Sleep Apnea? (please choose one)

Mild

Moderate

Severe

Have you been prescribed a Cpap to use? (Yes/No)(Required)

If yes, are you currently using the Cpap machine?

Date of Diagnosis

MM slash DD slash YYYY

Any surgical procedures? (Yes/No)

If yes, Date or procedure?

MM slash DD slash YYYY

Date of last Cardiac test?

MM slash DD slash YYYY

Type of Surgery or Medical Procedure:

Date of procedure:

MM slash DD slash YYYY

Do you receive more than 2 injections a year for your neck or back?

Have you had 2 or more prior back surgeries with ongoing chronic/recurrent back pain requiring treatment?

If yes, what type of procedure?

Outcome of procedure:

What was the date of procedure?

MM slash DD slash YYYY

Types of medical concerns not covered from above: (list here)

Diagnosis Date:

MM slash DD slash YYYY

Date of your last treatment?

MM slash DD slash YYYY

Have you had a physical check up with your health care provider in the last 2 years?(Required)

If yes, approximate date:

MM slash DD slash YYYY

In the last 5 years have you seen a Chiropractor?(Required)

If yes, reason for the visit?

Last date of appointment:

MM slash DD slash YYYY

Have you been hospitalized in the last 5 years for depression?

In the last 5 years have you seen a counselor/psychiatrist?(Required)

If yes, last date seen:

MM slash DD slash YYYY

What is the name of your immune system disease?

What date were you diagnosed?

MM slash DD slash YYYY

Any prescription medications taken during the past 2 years?(Required)

If yes, what type?

What was the date of last treatment?

MM slash DD slash YYYY

If yes, please list the medication(s) below- Name of Medication, dose of Medication, and reason you were prescribed:

Have you ever been diagnosed to be genetically predisposed or carry a gene that could develop diseases such as Cancer, Coronary artery disease, or Alzheimer's?(Required)

Do you participate in any of the following? (please select all of the following that apply)(Required)

Scuba Diving

Sky Diving

Bungee Jumping

Rock Climbing

Racing

Other

None of the Above

Are you a Doctor or In your Residency?(Required)

Type of Occupation:(Required)

Years in field of Occupation:(Required)

Are you Employed Full-Time?(Required)

Employer's Name:

Years Employed:

How many hours per week do you work?(Required)

Do you supervise employees?

If yes, how many?

Do you own your own business?(Required)

Type of business:

What is your percentage of ownership?

Total Number of employees:

Are you employed part time?(Required)

Employer's Name:

Years of Employment:

How many hours per week do you work?(Required)

Do you supervise employees?

If yes, how many employees:

Do you have any other Disability Insurance? (Yes/No)(Required)

If yes, Select the one(s) you have: (please select all that apply):

Individual

Group

Association

What is the Monthly Benefit and Are you going to replace this?

Consent

By checking this box, you are certifying that the information completed on this form is factual to your knowledge. You are giving OCI Insurance consent to submit a preliminary assessment with the Disability providers to determine potential eligibility and estimated rates.

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