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Disability Insurance Increase Questionnaire
0%
1
Insured
Information
2
Employment
Information
3
Financial
Information
Employment Information
Employer Details
Current Employer
Address Line 1
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Number of years with current employer
Less than two years
More than two years
More than five years
Months with current employer
Previous employer name
How many hours per week are you at work with this Current Employer(s)?
Do you plan to change your Current Employer within the next six months?
No
Yes
Please Explain
Employment Status
Employee
Sole Proprietor
Partner
S-Corporation Shareholder
C-Corporation Shareholder
Percent partnership
Percent partnership
Percent partnership
Within the past five years, have you applied for, or are you currently receiving, any disability benefits from any source?
No
Yes
Please provide details
Occupation Details
Occupation
Abdominal Surgery
Account Executive
Account Executive (Advertising)
Accountant (College Degreed)
Accountant (CPA)
Accountant (Other)
Actor | Actress
Actuaries
Acupuncturist
Administrative Assistant
Advertising Representative
Aerobics / Exercise Instructor
Aeronautical Engineer
Air Conditioning Engineer (Consulting Only)
Air Conditioning Engineer (Inspecting)
Air Conditioning Installer & Repair
Air Evacuation Personnel
Air Traffic Controller
Aircraft Groundcrew
Aircraft Pilot
Airport Dispatcher
Airport Manager (Supervisory Duties)
Airport Operations & Passenger Agent
Airport Reservations Clerk
Alarm Installer / Repair
Algologist
Allergist / Immunologists
Ambulance Driver
Analyst
Anchorman
Anesthesiologists
Announcer (Radio / TV)
Antenna or Tower Worker
Anthropologist
Antique Dealer (Purchasing / Repair)
Antique Dealer (Sales Only)
Appliance Repair
Appliance Sales
Appraisers
Arbitrageur
Architect
Armored Car Driver / Worker
Art Director
Art Director (Print Media)
Art Gallery Owner
Art Restorer
Artist or Graphic Artist (Full-Time Salary)
Asbestos Remover
Asphalt Worker
Assayers (Not in Mine)
Assembly Line Worker
Assessors
Astronomer
Athlete (Pro & Semi-Pro)
Athletic Director
Attendant (Parking)
Attorney
Auctioneers
Audio Visual Tech
Audiologists
Auditors
Authors (See Writers)
Bakery (All Others)
Bakery Managers & Proprietors
Bank Loan Officers
Bank Officers
Bank Portfolio Managers
Bank Tellers & Clerks
Biologists
Booking Agents (Full-Time)
Bookkeepers
Botanist
Building or Apartment Managers
Business Machine Sales & Services
Business Owner
Buyers (Department Store)
Cabinet Makers
Cantors
Car Body Shop Employee
Car Dealership Owner (Multiple Dealerships)
Car Dealership, Sales, Owners (New Vehicles)
Car Repairmen, Painter, Mechanic
Car Sales (Used Vehicles)
Car Wash Proprietors and Managers
Cardiologists
Cardiovascular Surgeons
Carpenters
Cashiers
Caterers (No Food Prep or Serving)
Chemists
Chiropractors
Clergymen
Clerks (Office)
Clothing Manufacturing, Managers, Designers
Collection Industry (Office Duties Only)
Colon and Rectal Surgery
Commercial Artists (Full-Time, Salaried)
Commodity Brokers (not exchange floor)
Comptrollers
Computer Analysts
Computer Consultants
Computer Industry Business Owner
Computer Programmers
Computer Repair, Service, Installers
Computer Sales
Computer Scientists
Computer Systems & Design Engineer
Construction Contractors w/ Executive Duties
Construction Contractors w/ Supervisory Duties
Construction Engineers
Construction Foremen & Supervisor
Consultants
Counselors
Data Engineer - Bachelors
Data Engineer - PE, PhD, Masters
Demographers
Dental Anesthesiologists
Dental Assistants
Dental Hygienists
Dental Technicians
Dermatologists
Designers
Developer
Diagnostic Surgery
Dieticians (Not Preparing Food)
Dieticians (Other)
Draftsman
Dry Cleaning Clerks, Managers
Dry Cleaning Deliverymen
Dry Cleaning Foremen
Ecologists
Economists
Editors (Magazine & Newspaper)
Electricians
Embalmers
Embryologists
Emergency Medicine
Employment Agency Owner or Recruiter
Endocrinologists
Endodontists
Engineer w/ Advanced Degree | Field Duties
Engineers (75% or more time is office based)
Engineers (less than 75% of time in office)
Engineers w/ Advanced Degree | Office Duties
Epidemiologists
Event Planners
Executives
Exporters & Importers
Express, Motor Freight, or Warehouse Agent, Estimator, Owner or Manager
Exterminator
Facial Plastic Surgery
Family Medicine
Farmers
Financial Planners
Fire Arms Inspectors, Repair, Sales Dealers
Firefighter
Florist Clerk & Arranger
Florist Manager & Merchants
Funeral Directors & Proprietors (Not embalming)
Furniture Designers
Futures & Options Brokers
Garage & Service Stations Owners
Gastroenterologists
General Dentists
General Practice Physicians
Geneticists
Geologists (in the field)
Geologists (office only)
Geophysicists
Geriatricians
Gynecological Oncologists
Hairdresser
Hand Surgery
Harbor Masters
Harbor Pilots
Head and Neck Surgery
Hematologists
Hospice and Palliative Medicine Physicians
Hospital or Nursing Homes Administrators
Hospital or Nursing Homes Managers & Clerks
Hospitalists
Immunologists
Income Tax Services
Infectious Disease MD
Insurance Adjuster
Insurance Agents, General Agents, & Brokers
Insurance Claims Adjusters
Insurance Claims Adjusters (Fire or Marine)
Insurance Claims Examiners
Insurance Office Managers
Insurance Surveyors, Underwriters, Clerical
Interior Decorators
Internal Medicine
Jewelry Store Clerks
Jewelry Store Owners & Managers
Judges
Lab Workers
Landscape Architect
Large Hotel Clerks
Large Hotel Owners & Managers
Lawyers
Librarians
Literary Agents
Lobbyists
Locksmiths
Machinists
Manager
Manufacturing Designers & Representatives
Manufacturing Executives & Owners
Manufacturing Managers & Foreman
Marina Owners & Managers
Market Research Executives & Owners
MBA Student
Mechanics
Medical Assistants
Medical Students (Undeclared)
Merchandise Brokers
Meteorologists
Midwives
Mining (Office Duties Only)
Mortgage Banker
Mortgage Brokers / Originators
Naturopaths
Neonatologists
Nephrologists
Neurological Surgery
Neurologists
Nurse Anesthetists (CRNAs)
Nurse Practitioners
Nurses - LPNs
Nurses RNs
Nursing Home Attendant
Obstetricians and/or Gynecologists
Occupational Therapists
Office Manager
Oncologists
Ophthalmologists
Opticians
Optometrists
Oral Surgeons
Orthodontists
Orthopedic Surgeons
Otolaryngologists
Pain Management Physicians
Paralegal
Paramedics (In Hospital)
Pathologists
Pediatric Dentists
Pediatric Surgery
Pediatricians
Perfusionist
Periodontists
Pharmacists
Phlebotomists
Photographer (Commercial. Studio)
Photographer (On-Site)
Physiatrists (Physical Medicine, Rehabilitation)
Physical Therapists
Physician Assistants
Physicists
Physiotherapists
Pipefitters
Plasterers
Plastic Surgeons
Plumbers
Podiatrists
Police Officer / Law Enforcement
Political Economists
Political Scientist
Private Equity Analyst / Banker
Programmers
Prosthodontists
Psychiatrists
Psychologists (Masters)
Psychologists (PhD)
Publishers
Pulmonologists
Radiation Oncologists
Radio / Television Production
Radiologists
Real Estate Appraisers
Real Estate Brokers
Resident Physicians (See Specialty)
Respiratory Therapists
Retail Sales
Rheumatologists
Sales Managers
Sales Professional
Scientists
Social Workers (PhD or MSW)
Social Workers (Private Agency)
Sociologists
Speech Therapists
Statisticians
Stock Brokers
Surgeons
Surgical Assistants
Surveyors
Tailors
Teachers
Thoracic Surgeon
Toxicologist
Translators
Traumatic Surgery
Travel Agencies
Ultrasound Technicians
Urologists
Vascular Surgery
Venture Capitalist
Veterinarians (Large Animal)
Veterinarians (Small Animal)
Working Foremen, Electricians, Mechanics, Pipe Fitters, Shipping and Receiving Clerks
Writers
Writers (Full-Time, Salaried)
X-Ray Technicians
Zoologists
Medical Board Specialty Certification
Medical Board Sub-specialty Certification
Are you any of the following
None
Student
Resident
Fellow
What is your expected graduation date?
What is your expected graduation date?
What is your expected graduation date?
Number of Years in Occupation
Job Title (If medical or dental occupation, state specialty)
Do you hold any academic degrees, professional licenses, and/or designations?
No
Yes
Please provide details
Description of Specific Duties
Duty
Percentage of Time Devoted
Remove Duty
Add Duty
Do you have any disability insurance in force or applied for, or for which you are eligible within the next 12 months with any company, including Guardian or Berkshire Life Insurance Company of America (âBerkshireâ)?
No
Yes
What is the monthly benefit amount of your disability insurance?