Legacy Insurance Agency
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R. Barry Page
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Pre-Application Questionnaire
0%
1
Insured
Information
2
Occupation
Information
3
Financial
Information
4
Additional
Information
5
Coverage &
Health Info
Occupation Information
Your Occupation
Number of Years in Occupation
How many hours per week are you at work in this occupation?
Job Title (If medical or dental occupation, state specialty)
Academic degrees, professional licenses and/or designations held (if none, so state)
Are you any of the following?
Student
Resident
Fellow
None
What is your expected graduation date
Description of Specific Duties
Duty
Percentage of Time Devoted
Remove Duty
Add Duty
Do you ever perform any manual duties such as operating machinery, carrying or lifting objects in excess of 30 lbs., climbing ladders, or driving a delivery vehicle?
No
Yes
Details
Do you ever wear any protective gear or attire?
No
Yes
Details
If you are a medical professional please provide your certifications below.
Medical Board Specialty Certification
Medical Board Sub-specialty Certification
Is this a home-based occupation?
No
Yes
What percentage of time are you working out of the home?
How many hours per week in this occupation?
Have you been continuously at work full time performing the usual duties of your occupation for the past six months?
No
Yes
Please explain
Do you supervise any employees?
No
Yes
How many employees?
Employment Status
Owner or Partner
Employee
Owner or Partner Type
Sole Proprietor
Partner
S-Corporation Shareholder
C-Corporation Shareholder
Percent partnership
Percent partnership
Percent partnership
Do you plan to change your occupation, job or employment within the next six months?
No
Yes
Please Explain
Do you have any other part or full time occupation, job or employment?
No
Yes
Please Explain