1.
What is you gender? Male Female
2.
Do you currently have disability insurance? *
No Yes - Individual Yes - Group Plan Unsecure
3.
What is your medical / dental specialty (please indicate if interventional or diagnostic)? *
4.
What is your employment status? *
Employee (of a physician group, dental group, hospital, etc)
Government Employee (City, State or Federal)
Independent Contractor / Locum Tenens
Resident Physician / Fellow
Year and Program Name:
Medical or Dental Student
Other
5.
What is your approximate income? *
Under $50,000
$50,000 - $100,000
$100,000 - $150,000
$150,000 - $200,000
$200,000 - $250,000
$250,000 - $300,000
$300,000 - $350,000
$350,000 - $400,000
$400,000 - $450,000
$450,000 - $500,000
Over $500,000
6.
In the past 12 months, have you used any tobacco products? *
Yes No
7.
What is your date of birth? *
Select Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select Month
January
February
March
April
May
June
July
August
September
October
November
December
Select Year
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
8.
What disability insurance provisions are important to you? (check all that apply)
Own occupation definition of disability
Guaranteed option to increase my monthly benefit in the future
Inflation protection (COLA)
Partial disability benefits (Residual Benefit)
Guaranteed renewable and non-cancelable
Insurance company with high financial strength ratings
Unsure – Please provide all options