Application Info- Ameritas DI – Disability Protection Partners

Years at this address?(Required)

Phone(Required)

Email(Required)

Driver's License Number(Required)

Driver's License State(Required)

Birth State or Country(Required)

Citizenship:

Visa Type:

Number of Years Residing in U.S.?

Current Height(Required)

Current Weight(Required)

Occupation (medical specialty, if physician}:(Required)

Years in Occupation(Required)

Employer Name (or name of school if full-time student}:(Required)

How long have you been employed by this employer?(Required)

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

List your day-to-day occupational duties:(Required)

If "Yes," provide details including hours per week:

If "Yes," provide details

If "Yes," give details, including employer, occupation(s), description of duties and hours worked per week:

If "Yes," provide details:

Approximate Income for 2023?(Required)

Approximate Income for 2022?(Required)

Approximate Income for 2021?(Required)

If "Yes" itemize sources and list amounts:

If "Yes," provide details, including: date filed, amount, location, date of discharge, status, etc.

How many years have you been an owner of this business?

What percent do you own?

How many other owners of this business are there?

How many total employees (other than owners) are there in this business?

If "Other" provide details:

Type

Insurance Company Name

Monthly Benefit

Percentage of Income Replaced?

Maximum Monthly Benefit?

Details regarding replacement or change:

Please provide those details: