Employee Disability Insurance Application

EMPLOYEE DISABILITY INSURANCE APPLICATION

Personal Information

Date of Birth:   Gender:

Marital Status:   Number of Dependents:

Position & Employer Information

Reporting Manager:   Hire Date:

Employment Status: Full-time Part-time Temporary

Annual Salary: $   Hourly Rate: $   Hours per week:

Coverage Requested

Requested Weekly Benefit: $   or Percent of Salary:

Elimination Period (waiting period before benefits):   Maximum Benefit Period:

Beneficiary / Payee

Medical & Health History

Have you ever been diagnosed with or treated for any of the following conditions? Select all that apply and provide details where indicated.

Cardiovascular disease (heart attack, stroke, etc.)
Respiratory disease (COPD, asthma requiring medication)
Musculoskeletal or spinal disorders (chronic back, neck)
Mental health condition (depression, anxiety, bipolar)
Diabetes or endocrine disorders
Cancer (malignant neoplasm)
Other (specify below)

Have you been hospitalized or undergone surgery in the last five (5) years? Yes No

Employment History (Last Two Employers Minimum)

Education

References (Professional)

Legal Disclosures

At-Will Employment: Employment and continuation of benefits are subject to employer policies and, where applicable, the terms of the group policy. Nothing in this application or acceptance of coverage is intended to alter the at-will employment relationship, unless expressly set forth in a separate written agreement signed by an authorized representative of the employer.

Equal Opportunity: The employer and insurer provide equal opportunity in all employment and benefits decisions without unlawful discrimination based on race, color, religion, sex, national origin, age, disability, genetic information, or any other protected characteristic under applicable law.

Certification, Authorization & Acknowledgement

I certify that all information contained in this application is true, complete and correct to the best of my knowledge. I understand that any material misstatement or omission of fact may result in denial of coverage, rescission of coverage or forfeiture of benefits and may subject me to criminal or civil penalties.

By signing below I authorize any physician, medical practitioner, hospital, clinic or other medical or medically related facility, my employer, and any consumer reporting agency or insurer to release to the employer, the group policyholder, and the insurance company or its agents any information the insurer requests regarding my medical history, treatments, prognosis, employment status, earnings, or other information necessary to underwrite, administer or adjudicate claims for disability benefits. I authorize the insurer to obtain investigative consumer reports and to verify information concerning employment and earnings history, prior claims, and other relevant records. A photographic or electronic copy of this authorization is valid as the original.

I acknowledge that coverage applied for is not in effect until accepted by the insurer and any required premiums are paid. I further acknowledge that benefits are subject to the terms and conditions of the applicable group policy and certificate, including limitations, exclusions, waiting periods, and pre-existing condition provisions.

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