MDI Pre-Application Info Questionnaire

Thanks for completing the form. The information received will be used to pre-populate your disability insurance application prior to sending to you for signature. For security purposes a save function is not available, so please complete the form in it’s entirety.

Pre-Application Info Questionnaire – MDI

Name

Gender

Date of Birth

MM/DD/YYYY

Address

Phone

Driver's License Number

Driver's License State

What state were you born in? Or country if outside the US

Are you a U.S. Citizen?

Yes

Type of Citizenship?

Non-resident U.S. citizen

Resident alien

Non-resident alien

Citizenship

Visa Type

Visa Number

Expiration Date

MM/DD/YYYY

Personal History Information

Have you been determined by a member of the medical profession to be disabled, or applied for any disability benefits?

Yes

If Yes, please provide those details

Within the last 12 months, have you used tobacco or other nicotine containing products except cigars (e.g. cigarettes, e-cigarettes/vape, pipes, snuff, chewing tobacco or nicotine delivery device such as gum or the patch?

Yes

Within the last 24 months, have you used tobacco or other nicotine containing products except cigars (e.g. cigarettes, e-cigarettes/vape, pipes, snuff, chewing tobacco or nicotine delivery device such as gum or the patch?

Yes

Have you used cigars in the last 24 months?

Yes

If Yes, provide number of cigars per year?

Have you used a prescription medication to assist with smoking cessation or as a substitute for smoking (e.g. Chantix, Wellbutrin, etc.) within the last 12 months?

Yes

Have you ever been convicted of a felony or currently on parole or probation?

Yes

Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs within the last 5 years?

Yes

Have you ever been in a motor vehicle accident in which you were found to be at fault, within the last 3 years?

Yes

Do you anticipate any foreign travel in the next 2 years?

Yes

If Yes, please provide details

Do you have a written agreement to become, or are you currently a member of the Armed Forces?

Yes

Do you expect to become within the next 2 years, or been in the last 3 years, a pilot, student pilot or crew member of any aircraft?

Yes

Do you take part in underwater diving, hang gliding, para sailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, helicopter skiing, or organized racing by automobile, motorcycle, motorboat or snowmobile, in the last 3 years or intend to in the next 2 years?

Yes

Please provide details:

Employment Information

Occupation (medical specialty, if physician)

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

Years in Occupation

If less than 2 years what was your previous occupation?

And for how long?

List your day-to-day occupational duties:

What percent of duties include physical activity such as climbing, crouching, lifting, etc?

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

Address

How long have you been employed by this employer?

What State do you work in?

For the last 90 days, have you been continuously at work for your usual and customary manner, performing all of the duties of your occupation without limitation due to injury or sickness?

Yes

If no, how many full or partial days during the specified period above has you missed work due to sickness or injury?

Please provide dates and details for any days of work missed, reduced work hours, or job restriction or modifications due to injury or sickness during the specified period above.:

Financial Information

Approximate Income for Current Year?

Approximate Income for Last Year?

Is your net worth (assets minus liabilities) greater than $10,000,000?

Yes

Business Ownership

Do you have any ownership in the business where you work?

Yes

What type of business is it?

Sole Proprietor

Partner in Partnership

Shareholder in Sub "S" Corp

Owner of a C-Corp

Owner of an LLC

Percent of ownership:

Number of full time employees:

Other Insurance Details

Do you currently have disability insurance in force??

Yes

Type

Percentage of Income Replaced?

Maximum Monthly Benefit?

Employer Paid?

Yes

Insurance Company Name

Monthly Benefit

Employer Paid

Yes

Will coverage be replaced or changed?

Yes

Do you have any other Disability Insurance not elsewhere listed on this form? Or, become eligible to participate in the next 12 months?

Yes

Please provide those details

If you are human, leave this field blank.