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ADV Part 2B
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Disability Insurance Worksheet
Name
Date of Birth
Date Format: MM slash DD slash YYYY
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Occupation/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:
Date Format: MM slash DD slash YYYY
Current Coverage & Avocations
Group LTD ?
Yes
No
Monthly Amount
Employer Paid
Yes
No
Individual DI?
Yes
No
Monthly Amount
Carrier
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