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Are you Self - Employed?
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If ``No", who is your employer?
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What type of business are you employed with?
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What is your position?
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How many years have you been with your current employer?
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Occupation (IMPORTANT be as specific as possible)
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Present Monthly Gross Income:
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$ |
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Monthly Benefit Requested: (What you will be paid monthly if disabled)
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$ |
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Please indicate tobacco use:
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Do you participate in any hazardous activities?
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Waiting Period: (time between injury and pay-out)
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Benefit Period:
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Please describe your
particular health problems:
(leave blank if none)
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Please list any medications
and dosage
(leave blank if none)
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Describe your family's history
of cancer and/or heart disease
(leave blank if none)
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