TEAMSTERS
Disability Insurance Client Questionnaire

Name __________________

Male _ Female ____

Phone: _____________________________ DOB(MM/DD/YY)____________
E-mail:_____________________________

Smoker Yes __ No __ (smoker is defined as anyone who has used any tobacco products within the last 12 months including any nicotine products or substitutes, marijuana or hash)

Occupation      __________________________________
Company           __________________________________
Primary Duties    __________________________________
Length of time in position     _________________________
Income   (current year)       _________________________
(last 2 years )    _________________________

Your Needs

What amount of income would you need a month to cover all
of your monthly expenses and income needs? (a) _____________

Group Insurance

If you have group disability coverage through work, how much
is the monthly benefit ?                                                                    (b) _____________
When do your benefits begin?       ____________
How long are they paid?               ____________
Does your employer pay any
portion of the premium?               ____________

Individual Insurance

If you own a personal disability insurance policy, how much
is the monthly benefit?                ____________
When do your benefits begin?      ____________
How long are they paid?              ____________

Amount of monthly insurance needed (a) – (b) _______

Your Opinion

Is a guaranteed, non-cancellable product important to you?
How long would like your waiting period to last?
How long would you like your benefit period to last?
Are there any other coverages you are interested in?
Do you have Critical Illness insurance already in place?