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Please Note: We only write insurance for these states.
What is your address?
What is your name?
What is your email address?
What is your fax number?
MM slash DD slash YYYY
Height (example 5' 8")
Do you have a pilot license of any type?
Do you participate in scuba diving, any racing, mountain climbing, hang gliding, skydiving, etc?
Have you had your drivers license suspended or revoked?
Have you been convicted of a felony?
Have you received disability compensation?
Have you been advised by a physician to reduce your alcohol consumption?
Do you smoke or chew tobacco?
Have you used LSD, cocaine or any illegal narcotics?
Is your health impaired in any way?
Are you taking medication?
Do you have high blood pressure?
Do you have asthma, emphysema or respiratory problems?
Do you have cancer or other tumors?
Do you have diabetes?
Do you have AIDS; HIV?
Are you pregnant?
Have you ever been declined life, health or disability insurance?
Are you a U.S. citizen?
Are you self-employed?
What is your occupation?
Please describe briefly your duties at your current job.
Is there a particular reason why you are purchasing disability insurance?
Do you have disability insurance now?
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