| Occupation Class: (pick what best describes your work) |
White Collar
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 Collar
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 Collar
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 Collar
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: |
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| Yearly Income: |
$
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| How much coverage do you need? |
|
| How long do you need coverage? |
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| Are you currently disabled? |
Yes
No |
| Are you, or will you be, pregnant in the next
10 months? |
Yes
No |
| Do you currently have disability insurance? |
Yes
No |
| Used tobacco in the last 12 months? |
Yes
No |
| Please describe any medical conditions: |
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| Do you own your home? |
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| When do you need coverage to start? |
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