Disability Insurance Worksheet Name Date of Birth MM slash DD slash YYYY StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificOccupation/Duties: Gender Male Female Ownership Yes No Ever Used Tobacco? Yes No If Company Ownership % Ownership Company # of Employees Income Known Health Issues: Known Prescriptions: Seen a Chiropractor in the last 24 Months? Y N Yes No Meeting Date: MM slash DD slash YYYY Current Coverage & Avocations Group LTD ? Yes No Monthly AmountEmployer Paid Yes No Individual DI? Yes No Monthly AmountCarrier