Guardian Disability Insurance Application

Guardian 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 5

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?*
* Please provide previous address:
Social Security Number*
Where were you born?*
Are you a U.S. citizen OR a permanent resident with a Green Card?*
When do you expect to obtain U.S. citizenship or permanent residency (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 5 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 10 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:
Is there a pending investigation or complaint concerning you with a regulatory, governmental, or other entity that oversees your profession, or have you ever been fined or sanctioned by an entity that oversees your profession?*
* Please provide details:
Have you participated within the last 3 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; parachuting; and/or paragliding?*
*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:
Current Height
Current Height (in Feet)*
Feet
Current Height (in Inches)*
Inches
Current weight

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:
Within the past six months, have you applied for disability or life insurance through any other company?*
* Please provide details:
Do you have any other disability insurance?*
Type of coverage:
* Type of coverage:
*Benefit Amount (if known):
* Benefit Amount (if known):
* Will you replace this policy?
* Will you replace this policy?
* Any other coverage?
* Any other disability coverage?
* Type of coverage:
* Type of coverage:
* Benefit Amount (if known):
* Benefit Amount (if known):
* Replacing?
* Will you replace this policy?
Who will pay the premium for this new disability policy?*
If your employer wil pay any part of the premium, will it be reportable by you as taxable income?*
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)?*
Bank Account Holder*
Financial Institution Name*
Type of Account*
ABA/Routing/Transit Number*
Account Number*
Would you like more information on the following...
- Life Insurance
- Long Term Care Insurance
- Financial Planning
- None of the Above
How did you hear about DoctorDisability?
Comments (optional)