Skip to content

About Us
Why Choose Us
Who We Serve
Contact

About Us
Why Choose Us
Who We Serve
Contact

PDI Pre-Application Info Questionnaire

Pre-Application Info Questionnaire – PDI

Name *

Name

Name

Name

Gender *

Birth State or Country *

Driver's License Number *

Driver's License State *

Last 4 SSN *

This will be your E-App PIN

Address *

Address

Address

Address

Address

Address

Address

Phone *

Email *

Are you a U.S. Citizen or a permanent resident with a Green Card? *

Yes

No

Is English your primary language? *

Yes

No

Citizenship *

Visa Type *

Number of Years Residing in U.S.? *

In the past 12 months have you used any tobacco or nicotine products? *

Yes

No

Tobacco or nicotine products includes: cigarettes, pipe, cigar chewing tobacco/snuff, hookah, e-cigarettes, vape or nicotine gum/patch

Premium Responsibility Information

Is any portion of the policy premium paid for by your employer or a business you own? *

Yes

No

If yes, what percentage? *

And will the premium be included as taxable income to you? *

Yes

No

Other Coverage

Do you have, are you applying for, or will you become eligible for in the next three years (based on a qualifying period of employment), any other Disability Insurance? *

Yes

No

Type *

Percentage of Income Replaced? *

Maximum Monthly Benefit? *

Employer Paid? *

Yes

No

*

Monthly Benefit *

Employer Paid? *

Yes

No

Will coverage be replaced or changed? *

Yes

No

Do you have any other Disability Insurance not elsewhere listed on this form? *

Yes

No

Please provide those details *

Employment/Financial Information

Occupation/Title (medical specialty, if physician) *

List your day-to-day occupational duties *

Is your unearned income greater than 20% of your earned income? *

Yes

No

Unearned income can include interest, dividends, capital gains, pension, annuity, alimony, net rental income, etc.

If "Yes" what is the source of your unearned income and total unearned income amount? *

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

Yes

No

If "Yes" what is your total net worth? *

Approximate Income for Current Year? *

Approximate Income for Last Year? *

Approximate Income for Previous Year? *

If you are human, leave this field blank.

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.

About Us
Why Choose Us
Who We Serve

Contact Us

9375 E Shea Blvd., Suite 100 Scottsdale, AZ 85260
info@diprotection.com
602.616.5598

Forms

Pre-Application Info Questionnaire – ADI
Pre-Application Info Questionnaire – PDI
Samaritan Health Medical Residents and Fellows
ApolloMD

Who We Serve

Advisors
Individuals
Associations
Employers

Contact Us

9375 E Shea Blvd., Suite 100 Scottsdale, AZ 85260
602.616.5598

Copyright © 2025 Disability Protection Partners | Designed by Accodelades

Scroll to Top