Disability Partner

A Division of David White & Associates
3150 Crow Canyon Place, Suite 200, San Ramon, CA 94583
P:800-955-0040 | F:925-277-2601

lyoung@dwassociates.com | kwoolsey@dwassociates.com | dthomas@dwassociates.com | scvetovac@dwassociates.com

 

 


Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

Note: If you do not hear back from us within 24 hours, please call 800-955-0040. Ask for Lisa or Kirk. Thank you!

*We respect your right to personal privacy. To that end, we collect and use the information you provide to us for quoting purposes only. The information we collect is never shared with other organizations and/or for commercial purposes. If you have any questions or concerns regarding this statement, please contact Don by email at: dthomas@dwassociates.com.

Disability Insurance Pre-Screening Questionnaire--For Broker Use Only



Broker Name: Broker Phone: Email:
Client Name: DOB(mm/dd/yyyy):
M/F: M F Occupation:

Daily Duties and Responsibilities:


Self Employed? yes If yes how many years?
How many employees? Years in this occupation:
Years with current employer:
Work from home office? yes no % of time in home:
Government Employee? yes no
Existing Group DI Benefits Individual DI Benefits
Annual Net Income: Current: Last: 2 Years Ago:

Medical History: (Neck, Back, Mental/Nervous, Blood Pressure etc.)


Medications: Height & Weight:
Tobacco User? yes no
Monthly Benefit Desired: Benefit Duration:
Coverage Type: Individual Overhead Expense Buy Out

Optional Riders:
Residual/Partial Disability:
yes no
True Own Occupation:
yes no
Guaranteed Non Can:
yes no
Future Purchase Option:
yes no
COLA:
yes no
Multi Life Discount (3 employees) :
yes no



 
 

malaga corp