Guardian Disability Insurance Application (Residents)

Welcome — Guardian Disability Insurance Application

You’ve selected Guardian, one of the most trusted disability insurance companies for
physicians.

We’re glad you’re here and happy to guide you through the next steps.

Before we ask a few questions, we want you to know what to expect. For residents and fellows, the process is simple — there is no medical exam and no income documentation required.

Nothing is final until you review and approve your policy.

Take a moment to review the steps below. When you’re ready, you can begin the application.

Here’s How the Application Process Works

Step 1: Complete the application

You answer a short health and training questionnaire.
Most residents finish in just a few minutes.

Step 2: Insurance company review

The insurance company reviews your application.
There is no medical exam and no income paperwork for residents and fellows.

Step 3: You receive an offer

The insurance company makes an offer with your benefit and price.

Step 4: You decide

You review the offer.
If it works for you, you accept it.
If not, you can make changes or walk away.

Paying your first premium

You have two options:

Pay now to allow for conditional coverage during review

Or wait and pay after approval

Both are okay.

Final approval

Nothing is final until you say yes.
You can make changes to your policy at any time during the application process.
Once your policy starts, you can cancel it at any time.

Let’s Get Started!

Step 1 of 5

Name
First Middle Last
Has your name changed in the past 5 years?*
Please provide your previous legal name*
First Middle Last
Gender Identity*
Date of Birth*
Month
Day
Year
This field is hidden when viewing the form
Age Calculation
Phone
Email*
Home Address
Street Address*
City*
State*
State*
Zip Code*
How long at this address?*
This field is hidden when viewing the form
* Please provide previous address:
Previous Address?*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Social Security Number*
State of Birth (Select 'Other' if other than U.S.)*
What country were you born in?*
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*
Visa Expiration Date
MM slash DD slash YYYY
Do you plan to reside in another country besides the U.S. in the next 2 years?*
Another Country details*
This field is hidden when viewing the form
Visa type? Visa duration?

Please choose your current occupation:*
Please list your occupation:*
This field is hidden when viewing the form
Archived: What is your current occupation/specialty?
Number of years in current occupation (including training)?*
Average number of hours worked per week in current occupation?*
Job Title:*
For medical occupations only: Please list medical board specialty and sub-specialty (if any):
List academic degrees, professional licenses, and or designations held (if none, so state):*
Are you any of the following?
What is the name of your program/school?*
Expected graduation date:*
MM slash DD slash YYYY
Medical/dental board specialty certification(s)
*If you can't find your specialty, select "Other"
Medical/dental board specialty certification(s): Other Details
Medical/dental board subspecialty certification(s)
Medical/dental board subspecialty certification(s): Other Details
Have you been continuously at work full time (at least 30 hours per week) performing the usual duties of your occupation for the past six months?*
* Please provide details:
Do you supervise any employees?*
* How many employees?
What is your current employment status?*
* Percentage ownership:
* Please provide details:
Do you plan to change your occupation, job or employment within the next six months?*
* Please provide details:
Do you have any other part-time or full-time occupations, jobs or employment?*
* Please describe other employment:
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:*
Have you or a business you've owned ever filed, or plan to file, for bankruptcy?*
* Please provide: type (personal or business), date filed, date discharged
Status
Date of discharge
MM slash DD slash YYYY

Within the last 5 years, have you made any claim for, or received, disability benefits from any source?*
Last 5 Years Applied for Disability Details*
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?*
* What company?
Do you have any other disability insurance?*
What company?
*What company? (if known):
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:
* Who pays for your group insurance?*
* Who pays for your group insurance?
* Benefit Amount (if known):
* Benefit Amount (if known):
* Replacing?
* Will you replace this policy?
Who will pay the premium for this new disability policy?*
What percentage of the premium for the coverage you are applying for will be paid by your employer? (0-100)*
Please enter a number from 0 to 100.
If your employer wil pay any part of the premium, will it be reportable by you as taxable income?*
Is your portion paid with:*
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)?*
Are you the bank account holder?*
Is the bank account holder a corporation?*
Corporation Name*
Name of Bank Account Holder*
First Last
Email of Bank Account Holder*
Address of Bank Account Holder*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Financial Institution Name*
ABA/Routing/Transit Number (Must be a Checking Account, not a Savings Account)*
Account Number (Must be a Checking Account, not a Savings Account)*
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?
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