Ameritas Agent Increase Application

Name
First Middle Last
Social Security Number
Date of Birth
Month
Day
Year
Gender
Phone
Email
Home Address
Street Address
City
State
Zip Code
How long at this address (years/months)?
Name of Current Employer
Employer Address
Street Address
Street Address 2
City
State
Zip
How many total employees at your place of work (approx.)?
Number of years with current employer?
What is your current occupation/specialty?
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 provide details:
Are you any of the following?
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:
Does your net-worth (excluding your home) exceed $4,000,000
Does your unearned income (rental properties, investments, etc.) exceed $20,000?
Untitled
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?
Desired amount of additional monthly benefit?
Would you like more information about...
- Life Insurance
- Long Term Care Insurance
- Financial Planning
- None of the Above
How did you hear about DoctorDisability?
Comments (optional)

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