Questionare Form - Drs Choices

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Insured Information

First Name*

Last Name*

Previous Last Name

Social Security Number*

Gender*

Male

Female

Address*

Street Address City State / Province / Region ZIP / Postal Code

How long have you lived at this address?*

Less than two years

More than two years

PREVIOUS ADDRESS*

Previous Street Address Previous City State Previous Zip

Date Of Birth*

MM slash DD slash YYYY

Place Of Birth*

Email Address*

Phone Number*

Are you a US Citizen or Green Card holder?*

Yes

Visa Type*

Visa Duration*

Has your residence in the U.S. been continuous?*

Yes

Do you expect to remain in the U.S. permanently?*

Yes

Please Provide Details*

Do you plan to reside in another country besides the US in the next 2 years?*

Yes

Please Provide Details*

When do you expect to obtain US citizenship or permanent residency (green Card)? Provide Details*

Employer Name*

Number of years with current employer*

More than two years

Less than two years

Months with current employer*

Previous employer name*

Nature of current Business*

CURRENT EMPLOYER ADDRESS*

Street Address City State Zip

Approximately how many people are employed by your current business/organization?*

Occupation Information

Your Occupation*

Number of Years in Occupation*

How many hours per week are you at work in this occupation?*

Job Title (If medical or dental occupation, state specialty)*

Academic degrees, professional licenses and/or designations held (if none, so state)

Are you any of the following?*

Student

Resident

Fellow

None

What is your expected graduation date*

MM slash DD slash YYYY

DESCRIPTION OF SPECIFIC DUTIES

Duty*

Percentage of Time Devoted*

Do you ever perform any manual duties such as operating machinery, carrying or lifting objects in excess of 30 lbs., climbing ladders, or driving a delivery vehicle?*

Yes

Details*

Do you ever wear any protective gear or attire?*

Yes

Details*

If you are a medical professional please provide your certifications below.

Is this a home-based occupation?*

Yes

What percentage of time are you working out of the home?*

How many hours per week in this occupation?*

Have you been continuously at work full time performing the usual duties of your occupation for the past six months?*

Yes

Please Explain*

Do you supervise any employees?*

Yes

How many employees?*

Employment Status*

Owner or Partner

Employee

Owner or Partner Type*

Sole Proprietor

Partner

S-Corporation Shareholder

C-Corporation Shareholder

Percent partnership*

Do you plan to change your occupation, job or employment within the next six months?*

Yes

Please Explain*

Do you have any other part or full time occupation, job or employment?*

Yes

Financial Information

Are you applying for Disability Insurance, Life Insurance, or Both?*

Net Worth*

For purposes of this section only, Earned Income means the income you are required to report to the Internal Revenue Service (“IRS”) for income tax purposes. This includes W-2 wages, salary, bonuses, your share of net business income, and all other compensation you received for work or services.

Current Income This Calendar Year*

Earned Income Actually filed with the IRS last Year.*

Earned Income Actually Filed with the IRS two calendar years ago.*

Do you have any unearned income that is more than 10% or your earned income?*

Yes

Last year's actual income filed*

2 Year's Ago actual income filed*

Source*

Have you or a business you’ve owned ever filed, or plan to file, for bankruptcy?*

Yes

Type*

Personal

Business

Date Filed*

MM slash DD slash YYYY

Date Discharged*

MM slash DD slash YYYY

Additional Information

Driver's License Number*

Driver's License State*

BENEFICIARY

Full Name*

Date Of Birth

MM slash DD slash YYYY

Type

Per Stripes*

Yes

Relationship to Proposed Insured*

Percentage %*

Social Security Number*

Phone Number*

Is Address same as Owner*

Yes

Address*

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

EXISTING INSURANCE/REPLACEMENT

1) Does the Applicant/Owner have any existing individual life insurance policies or annuity contracts (including those that may have recently been lapsed or surrendered)?*

Yes

2) As a result of the proposed purchase of life insurance, have you (the Applicant/Owner) done, or are you considering doing, any of the following to any existing life insurance policy or annuity contract that you own: lapse, partial lapse, surrender, forfeit, assignment to an insurer, termination of existing insurance; taking loans, withdrawals, or any other use of funds from your existing insurance ( including a stoppage or reduction in premium payments) to pay the premiums on the new life insurance policy?*

Yes

Do you plan to reside or travel outside of the U.S.?*

Yes

Untitled

Within the past five years, have you been charged with or convicted of any motor vehicle violations or had your driver's license suspended or revoked?*

Yes

Untitled

In the past 10 years, have you ever pled guilty to, pled no contest to, or been convicted of a felony or misdemeanor?*

Yes

Untitled

Within the last three years, have you participated, or do you plan to participate in piloting any type of aircraft or hang gliding?*

Yes

Untitled

Within the last three years, have you participated, or do you plan to participate in mountain or rock climbing, scuba diving, contact martial arts, motor vehicle racing, parachuting or skydiving or other hazardous activities?*

Yes

Untitled

Have you used tobacco, nicotine, or any nicotine delivery system in any form in the last 12 months?*

Yes

Untitled

Did you quit?*

Yes

Untitled

Are you now, or do you intend to become a member of the U.S. Armed Forces or have you received military orders or been placed on alert?*

Yes

Untitled

Do any of the following apply?

Your professional or occupational license or certification has ever been suspended, revoked, restricted, inactivated, surrendered, or the like.
There is a pending investigation or complaint concerning you with a regulatory, governmental, or other entity that oversees your profession.
You have been disbarred; or
You have ever been fined or sanctioned by an entity that oversees your profession.

Do any of the following apply?

Yes

Untitled

Coverage Health Information

Within the past five years, have you had any application for insurance declined, postponed, modified, rated, cancelled, rescinded, or have you withdrawn a pending application, or had a renewal or reinstatement request refused?*

Yes

Untitled*

Within the past six months, have you applied for life insurance through The Guardian Life Insurance Company of America ("Guardian") or any other company?*

Yes

Untitled*

Do you have any disability insurance in force, or applied for, or for which you are eligible within the next 12 months with any company? This includes any group LTD that you may have at work*

Yes

COVERAGE DETAILS

Insurance Company Name*

Status*

Is this coverage being replaced?*

Yes

Benefit Amount

Type of coverage*

Employer Paid*

Yes

Untitled*

Please tell us a little about your overall health*

PRE-APPLICATION QUESTIONNAIRE