Print out form
and mail to:
Roger Goldberg & Associates
2675 Tambridge Circle
Pensacola, Fl 32503
Dissability/Life Insurance Application -
1. PROPOSED INSURED: ___Male ___Female
First name__________________ Middle initial___ Last name_________________
Birthdate_________ Age at nearest birthday____ Birthplace(State or Country)_________
Social Security number_______________ Driver's license state/number_______________
2. Street Address__________________________
City_____________ State____ Zip_________
Home phone ( )______________
3. What is your occupation?______________________
Describe duties_______________________________
Employer______________________________________
Employer's street address____________________________
City__________________ State_____ Zip________________
Business phone ( )______________
If more information is needed, you can be reached at:
( )Home ( )Work Best time of day:__________
4. Current annual earned income:______________
5. Name of insurance plan_____________________________________
Initial death benefit $_______________
6. a. Have you smoked cigarettes in the past 36 months? ( )Yes ( )No
b. Have you used tobacco in any other form in the
past 36 months? ( )Yes ( )No
Type_____________ Quantity______________
7. a. Have you ever been told you had, or been treated for:
diabetes, cancer, heart disease, alcoholism, drug abuse,
or high blood pressure? ( )yes ( )No
(If Yes, preferred rates will not likely be available.)
8. Rate class applied for:
( )Preferred non-tobacco ( )Preferred tobacco
( )Standard non-tobacco ( )Standard tobacco
( )Other____________________________________
9. a. Bill frequency: b. Bill form:
( )Annual ( )Direct
( )Semi-annual ( )PAC (monthly only)
( )Quarterly ( )List (monthly only)
( )Monthly (PAC or list only) ( )Other_____________
(For PAC, complete authorization form.)
c. Planned periodic premium: (UL plans only) $________________
10. Are you a U.S. citizen? (If No, complete below.) ( )Yes ( )No
Country of citizenship______________ Type of Visa____________ Exp. date_______
11. Have you traveled or lived outside the U.S. or Canada within the past
two years, or do you intend to in the next 24 months? ( )Yes ( )No
(If Yes, list country, reason, frequency and length of stay in #22.)
12. In the past three years, have you had three or more moving violations,
or had your driver's license suspended or revoked? ( )yes ( )No
13. Have you ever been convicted of reckless driving, or driving under
the influence of alcohol or drugs? ( )Yes ( )No
14. Have you been convicted of, or are you awaiting trial for a
felony? (If Yes, give type, date & current status.) ( )Yes ( )No
15. In the past five years have you, or do you intend to:
a. Scuba dive ( )Yes ( )No e. Mountain climb ( )Yes ( )No
b. Sky dive ( )Yes ( )No f. Race motorcycles ( )Yes ( )No
c. Parachute ( )Yes ( )No g. Race automobiles ( )Yes ( )No
d. Hang glide ( )Yes ( )No h. Race power boats ( )Yes ( )No
(If Yes, explain frequency, purpose, date of last activity &future plans.)
16. In the past five years, have you flown as a pilot or crew
member in any flying activity, or do you intend to? ( )Yes ( )No
17. Have you ever had or been treated for:
a. High blood pressure, chest pain, rheumatic fever, a
heart condition, heart murmur, irregular heart
rhythm, heart attack, stroke, or other disease of
the heart or blood vessels? ( )Yes ( )No
b. Diabetes, a thyroid disorder, or other disease of
the glands? ( )Yes ( )No
C. Cancer, tumor, lymph gland disorder, cyst, or
any blood disorder? ( )Yes ( )No
d. Albumin, blood or sugar in the urine, kidney
trouble, or any other disease of the urinary or
genital tract (including prostate)? ( )Yes ( )NO
e. Epilepsy, convulsion, fainting spell, stroke, paralysis,
or any other disease of the brain or nervous system? ( )Yes ( )No
f. Asthma, chronic bronchitis, emphysema, pneu-
monia, sarcoidosis, tuberculosis, shortness of
breath, or other lung or respiratory system ailment? ( )Yes ( )No
g. Ulcer, colitis, hepatitis, pancreatitis or other
disorder of the esophagus, stomach, intestines,
liver, gallbladder or pancreas? ( )Yes ( )No
h. Severe injuries or any disease or deformity of the
muscles, connective tissue, bones, joints, or skin? ( )Yes ( )No
i. Any impairment of sight or hearing or disease of
the eyes, ears, nose or throat? ( )Yes ( )No
18. Have you ever:
a. Used narcotics, hallucinogens, barbiturates, heroin,
cocaine, amphetamines, or any other habit-forming
drugs except as prescribed by a physician? ( )Yes ( )No
b. Been advised by a physician, psychiatrist, or
psychologist to quit or reduce your alcohol use? ( )Yes ( )No
c. Been advised to seek, or received treatment or
counseling for alcohol or other drug use? ( )Yes ( )No
d. Been advised to attend or been a member of any
self-help group, such as Alcoholics Anonymous
or Narcotics Anonymous? ( )Yes ( )No
e. Been convicted of drug possession or distribution? ( )Yes ( )No
19. Have you:
a. Consulted a physician, psychiatrist, psychologist,
or other medical practitioner in the last five years? ( )Yes ( )No
b. Had any blood studies (other than an HIV or AIDS
test), electrocardiograms, stress electrocardiograms,
or other medical tests or studies in the last
five years? ( )Yes ( )No
c. Tested positive for the Human Immunodeficiency
Virus (HIV) or antibody? ( )Yes ( )No
d. Been under observation or received treatment in
any hospital or other institution or medical facility
in the last ten years? ( )Yes ( )No
e. Been advised, in the last two years, to have any
diagnostic test, surgery, or hospitalization which
has not been completed? ( )Yes ( )No
f. Ever received any sickness or disability pension,
benefits, or compensation? ( )Yes ( )No
g. Ever attempted suicide? ( )Yes ( )No
h. Have you lost any weight in the past year? ( )Yes ( )No
If Yes, amount?_____ Reason?_____________
i. Are you currently taking or have you been advised to
take any medication? ( )Yes ( )No
(If Yes, list name of medication, reason & doctor's name and address.)
20. To the best of your knowledge, do you have:
a. Any mental illness or psychiatric disorder? ( )Yes ( )No
b. Any physical disorder or disease? ( )Yes ( )No
21. Who is your personal physician? (If none, state none.)
Name_____________________________________________________
Street___________________________________________________
city__________________ State_____ Zip____________________
Date last seen?____________ Phone________________________
Why?_____________________________________________________
What tests were made?_____________________________________
Were the results normal? (If No, give details below.) ( )Yes ( )No
22. Details of Yes answers for #11-21.________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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