If you have any questions about your benefit plans, please don't hesitate to or call Kristen Garry at 267.794.3010.

To learn more about Gallagher Benefit Services visit tccgroup.com.

To learn more about the Cultural Alliance visit philaculture.org

Individual Long Term Disability

Insurance Questionnaire

(All Information is Confidential)

To furnish the appropriate product and quotation for you at the potentially lowest possible cost, please complete the following questionnaire. * denotes a required field.

I. Your Information

Name *

Company

Phone *

E-mail *

 

II. Coverage Design Questions
All proposals will provide coverage for home health care, intermediate care and nursing home care.

1.

What amount of daily coverage is needed?

2.

What percentage of your gross income do you need to protect?

50%   60%   67%

3.

How many days after a disability begins should benefits be paid?

30   60   90   100

4.

Is an automatic inflation adjustment important to you?

Yes   No

If Yes...

5% simple increase
5% compound annual increase

5.

How long should benefits continue?

2 years   5 years  
To age 65  Lifetime Benefits

6.

Do you want the coverage to coordinate with Social Security?

Yes   No

 

III. Personal Profile Questions

1.

Date of Birth

   

2.

Sex

 Female  Male

3.

Non-smoker?

Yes   No

Never smoked?

Yes   No

4.

Do you participate in a regular fitness program?

Yes   No

5.

Do you currently have disability coverage?

Yes   No

If yes, how much, and type of coverage (group or individual)?


Group   Individual

6.

Have you applied for any other insurance program during the past three years that was issued preferred?

Yes   No

 

IV. Medical History Qualification Questions

1.

Have you been treated for cancer, heart attack, diabetes or any disease of the liver, lungs or kidney? If so, full information is required, name and address of doctor, dates, and diagnosis.

Yes   No

2.

Are you currently receiving any medical advice or treatment for any medical, surgical or psychiatric condition?

Yes   No

3.

Have you used tobacco in any form in the past 12 months?

Yes   No