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Disability Insurance Request for Proposal

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CONTACT INFORMATION

MM slash DD slash YYYY
MM slash DD slash YYYY
Name(Required)
If you are an MD, are you in
Type of Employee

FINANCIAL & OTHER DISABILITY INSURANCE INFORMATION

Was this included in question #1?
Do you have group disability insurance through your employer?
Employer paid?
Is your bonus/commission income (if applicable) covered under your employer group disability policy?

BUSINESS OWNER - COMPANY INFORMATION

Do you have an outstanding business loan?

HEALTH INFORMATION

Within the last 10 years, have you received treatment or been advised to seek treatment for Drug or Alcohol abuse?
Within the last 10 years, have you filed a claim for disability benefits?
Within the last 10 years, has any application submitted for accident, sickness, hospitalization, major medical or life insurance been declined, postponed, or increased in rate?
Is foreign travel or residence contemplated?
Do you engage in: Piloting, scuba diving, rock climbing or hang gliding? If so, dates, activity, and how often?
Have you ever been declined, postponed, or rated on a previous disability insurance application policy?

If yes, answered to any of the following questions, please provide details.

Have you consulted or been treated by a licensed physician, psychotherapist, psychologist, or other health care professional in the last 10 years? (other than routine checkup)

Provide details if you're taking prescription medication or taken prescription medication in the last 3 years

To the best of your knowledge, are you now in good health and free from mental or physical impairment, abnormality, injury, or disease?

Get in Touch

Gallagher Affinity Insurance Services, Inc., provides administrative support services to insurance plans sponsored by associations and fulfilled by insurance carriers. Our support includes certificate issuance and facilitation of information in support of applications and claims for benefits provided by the insurance carrier. The carrier fulfills the benefit determination and any payments on claims associated with those benefits. Insurance brokerage and related services to be provided by Gallagher Affinity Insurance Services, Inc. (License No. 100310679 | CA License No. 0783129).

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