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Why Choose Us
Who We Serve
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SDI 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 – SDI

Name *

Name

Name

Name

Gender *

Address *

Address

Address

Address

Address

Address

Address

Primary Phone No. *

Email Address *

Last 4 SSN *

This will be used as your eApp PIN

Driver's License Number *

Driver's License State *

State of birth? Or country if outside the US *

Current Height *

Current Weight *

Occupational Information

Occupation (medical specialty, if physician) *

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

Financial Information

What is your annual earned income from your primary occupation? *

Last Year? *

Currently, is your passive income greater than 25% of your earned income or $50,000? (Passive income includes: capital gains, interest, dividends, net rental income, pensions, annuities, royalties, etc.) *

Yes

No

If "Yes" itemize sources and amounts: *

Is your net worth, excluding primary residence, greater than $8,000,000? *

Yes

No

If "Yes" itemize sources and amounts: *

Business Ownership

Do you own any part of, or are you an independent contractor for, the business where you work? *

Yes

No

If Yes, what type of business is it? *

C- Corp

S-Corp

LLC

LLP

Sole Proprietor

Partnership

Other

If Other, please provide type/details *

What percent do you own? *

Years owned? *

Number of employees? *

Number of employees? *

Other Insurance Details

Have you applied for any disability insurance in the last 12 months? Will you become eligible for any disability insurance in the next 24 months? Is there any other individual or group disability insurance currently in force or pending on you? *

Yes

No

Type *

Percentage of Income Replaced? *

Maximum Monthly Benefit? *

Employer Paid? *

Yes

No

Insurance Company Name *

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 *

Medical Information

In the last 5 years have you been treated for, or been diagnosed by a medical professional as having any heart condition, back or neck disorder, anxiety or depression, cancer, diabetes or neurological disorder? *

Yes

No

If Yes, please provide details. *

If you are human, leave this field blank.

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

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