Name:
Date of Birth:
Smoking status:
Income (annual- net after expenses):
Occupation:
Professional Designation(s) or Degree(s):
Employment Status:
Employee
Self-employed
Self employed with contract at one source
Self-employed with more than one contract
Other
Employment status (other – explained):
Please provide a breakdown of duties in % based on the following categories (Office duties, Supervisory, Manual, Driving, Travel (outside North America), Other (describe):
# of years in current industry or occupation:
# of years with current company or employer:
Is employment seasonal?:
If seasonal, number of weeks worked per year:
Any other part-time or full-time jobs (Describe)?:
Describe duties, number of hours worked, and income of the additional job(s):
Existing disability plan (explain – include how much it pays):
First year in business and on contract with current employer? Would you be able to obtain a letter from employer to support income to be earned, and length of contract?:
Please list any health conditions and medications taken:
If there are health conditions from above, please list dates of diagnosis and long-term prognosis. Is it affecting your ability to work?:
What are your expectations of the disability plan? What features are important to you?:
List any other occupation(s) and income per year from it:
Telephone number and best time to call:
Email Address:
