| Step 1 of 2 Basic Information |
| Your Gender: | | |
| Date of Birth: | |
| Height: | |
| Weight: | lbs. |
| Occupation: | |
| Occupation Class: (pick what best describes your work) |
White Includes professional or office-type occupations that are rarely exposed to physical or occupational hazards. Examples: Attorney, Accountant, Pharmacist, Indoor Sales, Architect, Consultants, Engineer, Secretary, Administrators, Computer Operators, Business Machine Repair. |
White-Grey Includes occupations similar to White but with certain activities or hazards involving laboratory, technical, supervisory, service work, and occasional driving. Examples: Doctor, Dentist, Outside Sales, Clergy, Speech Therapist. |
Grey-Blue Includes skilled and manual occupations in lighter industries, along with most machine operators. Examples: Electrician, Plumber, Mechanic, Construction, Carpenter, Parking, Inspection, Artisian, Truck Driver. |
Blue Includes occupations involving heavy manual labor, unskilled work and/or where there is increased risk of accident. Examples: Roofer, Painter, Crane operator,Furniture mover, Fire-fighter, Police, Delivery Drivers. |
| Are you self employed? | Yes No |
| Years at Job: | |
| Yearly Income: | $ |
| How much coverage do you need? | |
| How long do you need coverage? | |
| Are you currently disabled? | Yes No |
Are you pregnant or will be in the next 10 months? | Yes No |
Do you currently have disability insurance? | Yes No |
| Used tobacco in the last 12 months? | Yes No |
| If you have any medical conditions, please describe them below: |
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| Do you own a home? | |
| When do you need coverage to start? | |