Ameritas Agent 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.

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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)?
Years at this address?
Please enter a number from 1 to 75.
Social Security Number
State of Birth (Select 'Other' if other than U.S.)
What country were you born in?
Drivers License Number
Drivers License State
Are you a U.S. citizen OR a permanent resident with a Green Card?
Visa Type
Other Visa Details
Number of years residing in U.S.?
This field is hidden when viewing the form
Old Visa Field

Name of Current Employer
Employer Address
Street Address
Street Address 2
City
State
Zip
How many total employees are there in the business where the insured works (approx.)?
Number of years with current employer?
What is your current occupation/specialty?
Archived: Number of years in current occupation (including training)?
Number of years in current occupation (including training)?
Average number of hours worked per week in current occupation?
What is your current employment status?
Percentage Ownership?
Please enter a number from 1 to 100.
* Percentage ownership:
This field is hidden when viewing the form
How many years have you been an owner of this business?
How many other owners/partners are there?
Total Employees (Other Than Owners)
* Please provide details:
Do you work out of your home?
Home Based Business Details
Are you under any medical restrictions or limitations at work?
Please explain your medical restrictions or limitations:
Do you have any other occupation(s) not listed elsewhere on this application?
Please list your other occupation(s):
Are you planning on changing your employer or occupation in the next 180 days?
If yes, what is the name of your future employer/what occupation or medical specialty are you changing to?
Are you any of the following?
Expected Graduation Date:
MM slash DD slash YYYY
What is your approximate annual income (before taxes)? This includes W-2 wages, salary, bonuses, your share of net business income, and all other compensation you received for work or services.
Year to date:
Last year:
Two years ago:
Are you the owner of a business and contribute pension or profit share funds on your behalf to your business?
What is the annual contribution?
Does your net worth (assets minus liabilities) exceed $6,000,000?
Cash, Savings, Stocks, Bonds
Personal Residence
Other Real Estate
Business Interest
Personal Property
Other (Amount)
Is your unearned income (interest, dividends, capital gains, pension, annuity, alimony, net rental income, etc.) greater than 15% of your earned income?
Untitled
Have you or a business you've owned ever filed, or plan to file, for bankruptcy?
Type
Date
MM slash DD slash YYYY
Location
Status
Amount
This field is hidden when viewing the form
* Please provide: type (personal or business), date filed, date discharged

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:
Are you under a doctor's care for any condition?
What is your doctor's name?
First Last
Facility Name
What is your doctor's address?
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What is your doctor's phone number?
Month of Last Consultation
Year of Last Consultation
Please enter a number from 1950 to 2050.
Reason for Last Visit
Provide details of any medication/treatment given:
Are you currently taking any prescription medications?
Please provide details
Current Height
Current Height (in Feet)
Feet
Current Height (in Inches)
Inches
Current weight
Has your weight changed by more than ten pounds in the last twelve months?

Within the past five years, have you had any application for insurance declined, postponed, modified, rated, cancelled, rescinded, or have you withdrawn a pending application, or had a renewal or reinstatement request refused?
* Please provide details:
Do you have or are you applying for any other disability insurance?
* Including group disability insurance through your employer
Other Coverage Company
*What company? (if known):
Other Coverage Type
* Type of coverage:
Other Coverage Benefit Amount
* Benefit Amount (if known):
Group Insurance Benefit Amount
*Benefit Amount/Percentage of income covered (if known)
Group Insurance Elimination Period
* Waiting (Elimination) Period
Group Insurance Benefit Period
* Benefit Period
Group Insurance Payor
* Who pays for your group insurance?
Other Coverage Replacing
* Will you replace this policy?
Any other disability coverage?
* Any other disability coverage?
Other Coverage Company - 2
*What company? (if known):
Other Coverage Type - 2
* Type of coverage:
Other Coverage Benefit Amount- 2
* Benefit Amount (if known):
Group Insurance Benefit Amount - 2
*Benefit Amount/Percentage of income covered (if known)
Group Insurance Elimination Period - 2
* Waiting (Elimination) Period
Group Insurance Benefit Period - 2
* Benefit Period
Group Insurance Payor - 2
* Who pays for your group insurance?
Other Coverage Replacing - 2
* Will you replace this policy?
Who will pay the premium for this new disability policy?
Monthly benefit applying for?
This can be changed at any time during the underwriting process.
Would you like conditional coverage throughout the application process (requires payment of first month's premium)?
Would you like to hear more information about...
- Life Insurance
- Long Term Care Insurance
- Financial Planning
- None of the Above
How did you hear about DoctorDisability?
Comments (optional)

Ameritas Disability Insurance Pre-Application Questionnaire

Let’s Get Started!

Step 1 of 4

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