Application in Demo Mode
Your Disability Insurance Application
fill out the information below
Personal Profile
First Name
Middle Name
Last Name
Street Address
City
State
None
AL, Alabama
AK, Alaska
AZ, Arizona
AR, Arkansas
CA, California
CO, Colorado
CT, Connecticut
DE, Delaware
FL, Florida
GA, Georgia
HI, Hawaii
ID, Idaho
IL, Illinois
IN, Indiana
IA, Iowa
KS, Kansas
KY, Kentucky
LA, Louisiana
ME, Maine
MD, Maryland
MA, Massachusetts
MI, Michigan
MN, Minnesota
MS, Mississippi
MO, Missouri
MT, Montana
NE, Nebraska
NV, Nevada
NH, New Hampshire
NJ, New Jersey
NM, New Mexico
NY, New York
NC, North Carolina
ND, North Dakota
OH, Ohio
OK, Oklahoma
OR, Oregon
PA, Pennsylvania
RI, Rhode Island
SC, South Carolina
SD, South Dakota
TN, Tennessee
TX, Texas
UT, Utah
VT, Vermont
VA, Virginia
WA, Washington
WV, West Virginia
WI, Wisconsin
WY, Wyoming
N/A, Other
DC, Washington D.C.
Zip
Birth Date
State of Birth
None
AL, Alabama
AK, Alaska
AZ, Arizona
AR, Arkansas
CA, California
CO, Colorado
CT, Connecticut
DE, Delaware
FL, Florida
GA, Georgia
HI, Hawaii
ID, Idaho
IL, Illinois
IN, Indiana
IA, Iowa
KS, Kansas
KY, Kentucky
LA, Louisiana
ME, Maine
MD, Maryland
MA, Massachusetts
MI, Michigan
MN, Minnesota
MS, Mississippi
MO, Missouri
MT, Montana
NE, Nebraska
NV, Nevada
NH, New Hampshire
NJ, New Jersey
NM, New Mexico
NY, New York
NC, North Carolina
ND, North Dakota
OH, Ohio
OK, Oklahoma
OR, Oregon
PA, Pennsylvania
RI, Rhode Island
SC, South Carolina
SD, South Dakota
TN, Tennessee
TX, Texas
UT, Utah
VT, Vermont
VA, Virginia
WA, Washington
WV, West Virginia
WI, Wisconsin
WY, Wyoming
N/A, Other
DC, Washington D.C.
Gender
None
Male
Female
Social Security Number
Phone
Email
Driver's License Number
Driver's License State
None
AL, Alabama
AK, Alaska
AZ, Arizona
AR, Arkansas
CA, California
CO, Colorado
CT, Connecticut
DE, Delaware
FL, Florida
GA, Georgia
HI, Hawaii
ID, Idaho
IL, Illinois
IN, Indiana
IA, Iowa
KS, Kansas
KY, Kentucky
LA, Louisiana
ME, Maine
MD, Maryland
MA, Massachusetts
MI, Michigan
MN, Minnesota
MS, Mississippi
MO, Missouri
MT, Montana
NE, Nebraska
NV, Nevada
NH, New Hampshire
NJ, New Jersey
NM, New Mexico
NY, New York
NC, North Carolina
ND, North Dakota
OH, Ohio
OK, Oklahoma
OR, Oregon
PA, Pennsylvania
RI, Rhode Island
SC, South Carolina
SD, South Dakota
TN, Tennessee
TX, Texas
UT, Utah
VT, Vermont
VA, Virginia
WA, Washington
WV, West Virginia
WI, Wisconsin
WY, Wyoming
N/A, Other
DC, Washington D.C.
Current Primary Occupation / Duties
Premium Mode
EFT (Monthly)
List Bill (Monthly)
Annual
Other
Other Coverage
Have You Applied For Any Disability Coverage in the last 12 months?
Yes
No
Will You Become Eligibile for Any Disability Insurance in the next 24 months?
Yes
No
Is there any other individual or group disability insurance currently in force or pending on you?
Yes
No
Other Insurance Coverage
Plan 1
Plan 2
Company
Status
None Selected
Now In Force With Any Company
Pending
Applied For In Last 12 Months
Will Become Eligible in the Next 24 Months
None Selected
Now In Force With Any Company
Pending
Applied For In Last 12 Months
Will Become Eligible in the Next 24 Months
Type
None Selected
Individual
Group
Association
Overhead Expense
Loan Repayment
Other
None Selected
Individual
Group
Association
Overhead Expense
Loan Repayment
Other
Who Pays Premium?
Benefit Amount or % of Income
(If Group) Benefit Cap Maximum
(If Group) Bonus covered?
Select One
Yes
No
Select One
Yes
No
Benefit Period
Select One
2 years
5 years
10 years
To Age 65
To Age 67
Select One
2 years
5 years
10 years
To Age 65
To Age 67
Benefit Waiting Period
Select One
60 days
90 days
180 days
365 days
Select One
60 days
90 days
180 days
365 days
Will Coverage Be Replaced or Reduced?
Select One
Yes
No
Select One
Yes
No
Financial Profile
How Many Hours a Week To You Work In Your Primary Occupation?
What is Your Annual Earned Income From Your Primary Occupation?
Current Year (2023)
$
Previous Year (2022)
$
Currently, is your passive income greater than 25% of your earned income or $50,000?
Yes
No
Sources & Amounts
1
2
Sources
Amounts
Is your net worth, excluding primary residence, greater than $8,000,000
Yes
No
Sources & Amounts
1
2
Sources
Amounts
Will Your Employer pay for any part of this requested insurance?
Yes
No
Employer Information
What percent of premium will your employer pay?
Select One
None
100%
Other
Will your employer's contribution be included in your taxable income?
Yes
No
Will you reimburse your employer for any premium?
Yes
No
Do you own any part of, or are you an independent contractor for, the business where you work?
Yes
No
Business Information
Business Entity
Select One
C-Corp
S-Corp
LLC
LLP
Sole Proprietor
Partnership
Number of Employees
Full-Time
Part-Time
Percent Of Business Entity Owned
Percentage
Years Owned
Health Overview
Please Enter Your Build Information
Height (Inches)
Weight (lbs)
In the last 5 years have you had, been treated for, or been diagnosed by a medical professional as having any heart condition (such as heart attack, heart arrhythmias, or valvular disease or damage); back or neck disorder (such as whiplash or herniated disc); anxiety or depression; cancer, diabeted, or neurological disorder (such as stroke, epilepsy, multiple sclerosis, or carpal tunnel syndrome)
Yes
No
Health Information
Please Provide Details: Dates, Diagnoses, Treatments, Health Care Provider Name(s) and Address(es)
Exit and Return To Home Screen
This Application is in Demo Mode
The following application is in a demonstration mode. None of your information will be saved, and will be cleared as soon as you exit the page.
Thank you,
The DINGO Team
