Long-Term Disability Insurance Application
Personal Information
Full Name
Date of Birth
Social Security Number
Address
City
State
Zip Code
Phone Number
Email Address
Employment Information
Employer Name
Occupation/Job Title
Employer Address
Employer Phone
Employment Start Date
Annual Income
Disability Details
Type of Disability
Date Disability Began
Description of Disability
Treating Physician
Physician Phone
Treatment Received
Insurance Details
Do you have existing long-term disability insurance?
Yes
No
If yes, please provide details
Authorization & Signature
Signature
Date