Use can also use this form for Business Owner Expense Insurance

Personal Information                                                       * Required Fields
	* Your Name:
	* Your Address:
	* City:
	* State:		NV Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New York New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wyoming Wisconsin Washington D.C.
	* Zip Code:
	* Phone Number:		-
	Work Phone Number:		-   Ext.
	* Best time to contact you:		Select Morning / Home Morning / Office Afternoon / Home Afternoon / Office Evening / Home Evening / Office
	* Your E-mail Address:
General Information
	* Your Gender:		Choose One Male Female
	* Your Date of Birth:		Month January February March April May June July August September October November December / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
	* Marital Status:		Choose One Single Single-Parent Married Separated Divorced Widowed
		Spouse's Full Name:
		Spouse's  Date of Birth:	Month January February March April May June July August September October November December / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
Work Information
	* Occupation:
	* How Many Years at this Occupation:
	* Exact Duties:
	* % of your work that requires travel:
	* Annual Earned Income:
	Annual Un-Earned Income:
	Do you work out of your home?		Yes No
	If so, what % of time is in the home?
	Government Employee?		Yes No
	Business Owner?		Yes No
	If so, what % ownership?
	Number of employees?
	Type of Company?		Sole Proprietor Corporation - C Company - LLC Partnership S-Corporation
Policy Information
	* Other Disability Insurance in Force?		Yes No
	Amount of Long Term Group Disability:
	Coverage paid for by?		Self Employer
	- Current Insurance Carrier?
	Amount of Short Term Group Disability:
	Coverage paid for by?		Self Employer
	- Current Insurance Carrier?
	Amnt. of Individual Long Term Disability?
	- Current Insurance Carrier?
	Amnt. of Individual Short Term Disability?
	- Current Insurance Carrier?
	Who is paying for new premium?		Self Employer
	Would the intention of this policy be to replace any existing policy's?		Yes No
	Desired Elimination Period:		60 days 90 days 180 days 365 days 2 years
	Desired Benefit Period:		2 years 3 years 5 years To age 65 To age 67
	* Desired Benefit Amount (monthly):
	Renewable Option? This will allow you to renew  the policy beyond the termination date under the Renewable Option if you are still working at least 30 hours per week		Yes No
	Supplemental Social Insurance Rider? (SSIR) This rider pays a benefit if a total disability benefit is payable under the policy, and no legislated benefits are payable for the disability.		Yes No
	Future Purchase Option Benefit Rider? This rider allows benefit increases to be purchased at each policy anniversary subject only to financial underwriting requirements.		Yes No
	Indexed Cost of Living Benefit Rider? This rider pays an additional benefit after 365 days of disability. The benefit payable under this rider is a percentage of the base amount plus any benefit payable under the SSIR, if part of the policy. The percentage applied will be based on the consumer price index increase for the prior year, up to 6%.		Yes No
*Do you participate in any "extreme" sporting activities? i.e. Scuba Diving, Rock Climing, Hang Gliding etc.....			No Yes
		If Yes, please specify:
	* State of Residency:
	* State of Application:
Medical Information
* Do you currently own a Long-term    Care Insurance policy?			No Yes
* Have you had a complete routine     Health exam within the past 2 years?			No Yes
*Are there any health issues,     concerns or comments?			No Yes
		If Yes, please specify:
	* Tobacco Usage:		Non Smoker Under 1 Year 1 to 2 years Over 2 years
	* Do you take any prescription medications?   No Yes
		If Yes, please specify types and dosage:
	Additional Comments: