Ameritas Disability Insurance Application

Ameritas Disability Insurance Pre-Application Questionnaire

We will use the information requested in this pre-application questionnaire to help prepare your formal e-Application, which requires your review and authorization before being submitted to the insurance company. A separate secure link will be sent to you when this process is complete.

Let’s Get Started!

Step 1 of 4

Name
First Middle Last
Gender*
Date of Birth*
Month
Day
Year
Phone*
Email*
Home Address
Street Address*
City*
State*
Zip Code*
How long at this address (years/months)?*
Social Security Number*
Where were you born?*
Drivers License Number*
Drivers License State*
Are you a U.S. citizen OR a permanent resident with a Green Card?*
Visa type? Visa duration?

Are you currently scheduled to reside or travel outside the U.S. within the next 2 years?*
* Please provide details (location, work/pleasure, departure date, length of stay, etc.):
Within the last FIVE years, have you been charged with or convicted of reckless driving, driving while intoxicated, or any motor vehicle violation(s); had your driver’s license suspended or revoked; or been involved in any accident in which you were found at fault?*
* Please provide details:
Within the last FIVE years, have you been convicted of a felony or misdemeanor?*
* Please provide details:
Has your professional or occupational license or certification ever been suspended, revoked, restricted, inactivated, surrendered, or the like?*
* Please provide details:
Have you participated within the last FIVE years, or do you intend within the next 2 years, to engage in any of the following activities: contact martial arts; mountain or rock climbing; motor sports or racing (auto, truck, cycle, boat, etc.); scuba diving; skydiving; hang gliding; bungee jumping; ballooning; parachuting; paragliding; and/or piloting?*
*Please provide details:
Have you used any tobacco or nicotine products and/or nicotine delivery systems including vaping/hookah in the last 12 months?*
*Please provide details:
Are you currently a member of the US armed forces or National Guard, have you received military orders to appear for service, been placed on alert, or have you entered into a written agreement to become a member of the military?*
* Please provide details:
Within the last five years, have you been treated for, or been diagnosed by a member of the medical profession as having a heart condition, chest pain, stroke, back or neck problem, sleep disorder, psychological condition (including, but not limited to, counseling from a mental health or substance abuse provider, and/or psychotherapy), cancer, diabetes, alcohol abuse, or drug dependency?*
*Please provide details, including dates and healthcare provider’s name and address:
Are you currently taking any prescription medications?
*Please provide details:
Current Height
Current Height (in Feet)*
Feet
Current Height (in Inches)*
Inches
Current weight*