Trusted Physician Disability Insurance & Life Insurance

Personal Info

First Name

Last Name

Primary Email

Phone Number

Let's Get This Started

What Is Your Occupation Status Currently?

Medical School

Medical School Program/Institution

Other Medical School Program/Institution

Medical School End Date

Current Annual Income

Upcoming Residency

Are You Starting Residency Soon?

Yes

No

Upcoming Residency Program/Institution

Other Upcoming Residency Program/Institution

Residency

Resident Program/Institution

Other Resident Program/Institution

Are you a chief resident?

Yes

No

Residency End Date

Current Annual Income

Are You Starting Fellowship Soon?

Yes

No

Fellowship Program/Institution

Other Fellowship Program/Institution

Have You Signed An Employment Contract Yet?

Yes

No

New Employer Information

New Employer Name

Other New Employer Name

Expected Start Date

Expected Annual Income

New Employer State

Group Coverage

Will you be covered by an employer group disability plan?

Yes

No

Maximum Monthly Benefit

Percentage of Income Covered

Does Your Employer Pay The Premiums?

Yes

No

Fellowship Information

Fellowship Program/Institution

Other Fellowship Program/Institution

Fellowship End Date

Current Annual Income

Have You Signed An Employment Contract Yet?

Yes

No

New Employer Information

New Employer Name

Other New Employer Name

Expected Start Date

Expected Annual Income

New Employer State

Group Coverage

Will you be covered by an employer group disability plan?

Yes

No

Maximum Monthly Benefit

Percentage of Income Covered

Does Your Employer Pay The Premiums?

Yes

No

Career Information

Employer Name

Other Employer Name

Current Annual Income

Did You Finish Training In The Last 6 Months?

Yes

No

Training Program Graduation Date

What was the name of your program or institution?

Other What was the name of your program or institution?

Group Information

Are You Covered By Long Term Employer Group Disability Insurance?

Yes

Not Sure

No

What Is The Maximum Monthly Benefit Amount?

What Percentage Of Your Income Does It Cover?

Does Your Employer Pay The Premiums?

Yes

No

Are You Changing Employers Soon?

Yes

No

New Employer Information

New Employer Name

Other New Employer Name

Expected Start Date

Expected Annual Income

New Employer State

Group Coverage

Will you be covered by an employer group disability plan?

Yes

No

Maximum Monthly Benefit

Percentage of Income Covered

Does Your Employer Pay The Premiums?

Yes

No

Career Information

Employer Name

Other Employer Name

Current Annual Income

Please Provide Your Primary Occupational Duties

Total % of Time: Your total duties percentage cannot exceed 100%

Group Information

Are You Covered By Long Term Employer Group Disability Insurance?

Yes

Not Sure

No

What Is The Maximum Monthly Benefit Amount?

What Percentage Of Your Income Does It Cover?

Does Your Employer Pay The Premiums?

Yes

No

Are You Changing Employers Soon?

Yes

No

Health

Height

Weight

Medical History

Do You Currently Have Any Medical Conditions?

Yes

No

List All Medical Conditions With Dates and Treatments

Do You Currently Take Any Medication?

Yes

No

Please Provide The Name, Dosage, And Purpose Of Each Medication

Within The Past 10 Years Have You Been Hospitalized Or Undergone Any Surgery?

Yes

No

List All Including Dates, Treatment, and Outcome

Basics

Date of Birth

Gender

Male

Female

State of Residence

Specialty

Other Specialty

Final Questions

Citizenship Status

US Citizen

Permanent US Resident

Foreign Citizen

In Which Country Are You A Citizen?

What Type Of Visa/Green Card Do You Have?

J-1

H-1B

O-1

F-1

L-1

DACA

Are You Active Duty?

Yes

No

Current Discharge Date

How Did You Hear About Us?

What is their Name?

Are You Interested In Your Life Insurance Options?

Yes

No

Any Additional Comments or Questions?