Fillable Application For Disability Insurance (Oregon Home Care Commission Workforce)

Fill Online, Printable, Fillable, Blank Application For Disability Insurance (Oregon Home Care Commission Workforce) Form

Use Fill to complete blank online OREGON HOME CARE COMMISSION WORKFORCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application For Disability Insurance (Oregon Home Care Commission Workforce)

On average this form takes 66 minutes to complete

The Application For Disability Insurance (Oregon Home Care Commission Workforce) form is 5 pages long and contains:

  • 4 signatures
  • 186 check-boxes
  • 160 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Oregon Home Care Commission Workforce forms online.

BROWSE OREGON HOME CARE COMMISSION WORKFORCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Disability Insurance Application - 04-15-2021
Application For Disability Insurance
Petersen International Underwriters
PLEASE INITIAL THE FOLLOWING - I have read or had read to me and understand each of the questions and statements on this
entire application and no one has prevented me from spending as much time as I felt was necessary to understand this application.
PART I.
Applicant’s Name:
Date of Birth:
Address:
E-mail:
Employer’s Name:
Employer’s Address:
Occupation:
Specialty:
Policy Owner:
Owner Address:
Payment Mode:
Bill To:
(Please Select One)
First ________________________ M.I. ______ Last ________________________ Designation:__________
_______ / _______ / ___________ Height: ____________ Weight: __________ Sex: qMale qFemale
_________________________________________________________________________________________
City ________________________ State _________________ Zip Code ______________________________
__________________________________________________ Telephone (_______) _________ - ___________
_________________________________________________________________________________________
_________________________________________________________________________________________
City ________________________ State _________________ Zip Code ______________________________
____________________________ Daily Duties: _________________________________________________
____________________________ Length of Service: _____________________________________________
_____________________________________ Loss Payee: __________________________________________
(If other than Insured) (If other than Insured)
_________________________________________________________________________________________
City ________________________ State _________________ Zip Code ______________________________
q Multi-Year Prepay q Annual q Semi-Annual q Quarterly q Monthly (EFT/CC)
q Applicant’s Address q E-mail q Owner’s Address q Employer - Attn: _____________________
q Other: _________________________________________________________________________________
Producer #:____________
1. Are you actively at work?
2. Is foreign travel or residence contemplated?
3. Has your occupation changed within the last 2 years?
4. Do you ever participate in hazardous sports or hobbies?
5. Do you engage in volunteer civil service or emergency responding?
6. Are you a party to any legal proceeding at this time?
7. Are you aware of any fact that could change your occupation or nancial stability?
8. Do you have or have you ever had a professional license for your occupation?
9. If the answer to Question 8 is “Yes” has that license ever been suspended, revoked, restricted or has
there ever been any hearing, or is a hearing pending concerning that professional license?
10. Have you ever been convicted of any felony or misdemeanor or do you have any charges pending?
11. Have you or any business of which you had any ownership in led for bankruptcy in the last 5 years?
12. Have you had a driver’s license suspended or revoked in the last 3 years; been convicted of 3 or more
moving violations; been convicted of driving while impaired or intoxicated?
13. Have you ever had disability, life, health, or accident insurance declined, postponed, cancelled, rated,
or modied, or reinstatement of such refused?
Details: ____________________________________________________________________________________________
___________________________________________________________________________________________________
If “Yes” is answered for any of the following questions please provide full details in the space below.
If there is not sucient space, please aach your answers on a separate sheet.
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
q   Yes q   No
Page 1 of 4
Disability Insurance Application - 04-15-2021
Application For Disability Insurance
Petersen International Underwriters
PLEASE INITIAL THE FOLLOWING - I have read or had read to me and understand each of the questions and statements on this
entire application and no one has prevented me from spending as much time as I felt was necessary to understand this application.
PART I.
Insurer Issue Date Personal DI Monthly Benet Business Overhead Monthly Benet Buy/Sell Disability Other Disability
17. If a proposal was obtained, please provide the proposal number being applied for (lower le corner): _______________________
18. q Personal q Overhead Expense q   Key Person   q   Loan Indemnication q   Buy/Sell Other q   ____________
19A. Section I — Monthly Benets (if applicable)
Monthly Benet requested: ___________________ US$
Elimination Period requested: ___________________ Days
Benet Period requested: ___________________ Months
19B. Section I - Optional Riders:
q   Residual
q   COLA
q   Partial (Key Person Only)
q   Prime Flex (Loan Indemnication Only)
q   Salary Replacement Rider Requested: ___________________ (Overhead Expense Only)
20. Section II — Lump Sum Benet (if applicable)
Principal Sum requested: ___________________ US$
Elimination Period requested: ___________________ Months
14. What was your gross earned income less business
expenses, but before taxes from your profession?
15. What was “other income” from dividends, interest,
rents, royalties, estates and trusts, etc.? (Circle items.)
16. a) What was contributed to IRA, HR10, qualied pension
or prot-sharing plan?
b) Is this included in #14? q   Yes q   No
US$ _____________
US$ _____________
US$ _____________
21. Does your employer provide disability benets or salary continuation benets?
24. Are you terminating any existing policies listed above in order to qualify for the coverage now being applied for?
If “Yes” please indicate the coverage that is to be terminated. _______________________________________________________
22. Please list all disability insurance (including individual, group, mortgage, and credit plans) for
which you are applying, have in force, or are reinstating. If none, please indicate “None”.
Current YTD
20___
L as t Ye ar
20___
Two Years Ago
20___
US$ _____________
US$ _____________
US$ _____________
US$ _____________
US$ _____________
US$ _____________
Please indicate the type of coverage and the amount of coverage that you are applying for.
23. Do any of the above disability policies have any exclusions or ratings?
If “Yes” please advise _______________________________________________________
Page 2 of 4
q Yes q No
q Yes q No
q None
q Yes q No
Disability Insurance Application - 04-15-2021
Application For Disability Insurance
Petersen International Underwriters
PLEASE INITIAL THE FOLLOWING - I have read or had read to me and understand each of the questions and statements on this
entire application and no one has prevented me from spending as much time as I felt was necessary to understand this application.
PART II.
Question # Details of Conditions/Treatment Date & Duration Details and Degree of Recovery Doctors & Hospitals with Addresses
( Use additional sheets if needed)
a. Eyes
b. Ears
c. Nose
d. Cyst
e. Gout
f. Knees
g. Skin
h. Liver
i. Heart
j. Blood
k. Bones
l. Glands
m. roat
n. Hernia
o. Cancer
p. Asthma
q. Muscles
r. Kidneys
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
25. Primary care physician:
a. Name & address: ___________________________________________________________________________
b. Date and reason last seen: ___________________________________________________________________________
c. Results of last visit: ___________________________________________________________________________
26. Healthcare provider(s) seen in the last 3 years: (other than the primary care provider above)
a. Name & address: ___________________________________________________________________________
b. Date and reason last seen: ___________________________________________________________________________
c. Results of last visit: ___________________________________________________________________________
a. Name & address: ___________________________________________________________________________
b. Date and reason last seen: ___________________________________________________________________________
c. Results of last visit: ___________________________________________________________________________
a. Name & address: ___________________________________________________________________________
b. Date and reason last seen: ___________________________________________________________________________
c. Results of last visit: ___________________________________________________________________________
If “Yes” is answered for any of the following questions please provide full details in the space below. If there is not sucient space, please attach your answers on a separate sheet.
27. Have you ever been evaluated or treated for any injury, condition or disorder involving the following?
28. Have you used tobacco or other sources of nicotine at any time within the last three years?
29. Has your weight increased or decreased more than 10 pounds within the last year?
30. Are you now taking/using prescription medication and/or nonprescription medication?
31. In the last 60 days, have you taken any medicines which are not listed in #30?
q Yes q No
q Yes q No
q Yes q No
q Yes q No
ak. High blood pressure
al. Reproductive system
am. Arms/hands/legs/feet
an. Convulsions/Seizures
ao. Diabetes/Pre-Diabetes
ap. Are you now pregnant?
aq. Urinary system/Bladder
ar. Blood Clotting/Bleeding
as. Lungs/Respiratory System
at. Arthritis/joints /rheumatism
au. Mental/Emotional/Psychiatric
av. High Cholesterol/Triglycerides
aw. Blood vessels/Circulatory System
ax. Disorder of the brain/brain injury
ay. Gastrointestinal tract/Stomach/Esophagus
az. Any condition not mentioned previously?
s. Allergies
t. yroid
u. Pancreas
v. Chest pain
w. Headaches
x. HIV/AIDS
y. Sleep apnea
z. Gall bladder
aa. Concussions
ab. Tuberculosis
ac. Lymph nodes
ad. Growth/tumor
ae. Nervous system
af. Chronic Fatigue
ag. Back/spine/neck
ah. Unconsciousness
ai. Fainting/dizziness
aj. Paralysis/weakness
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
Page 3 of 4
Disability Insurance Application - 04-15-2021
Application For Disability Insurance
Petersen International Underwriters
Page 4 of 4
IT IS UNDERSTOOD AND AGREED:1) that all answers to the questions on this application, to the best of my knowledge and
belief, are complete and true, 2) that all answers on this application shall form the basis of the issuance of any coverage hereunder,
3) that in the event of any fraud, misstatement, concealment, or failure to disclose information in response to any question on this
application, whether intentional or inadvertent, any insurance coverage issued based upon this application may become void, and no
benets shall be payable, and 4) the insurance hereunder applied for shall take eect on the date set forth on the certicate, if issued,
provided the rst premium and all requirements are received within 31 days of the eective date and there have been no changes to
any questions on this application between the date of application and the eective date of the certicate. 5) I have read or had read
to me and understand each of the questions and statements on this entire application. 6) No one has prevented me from spending as
much time as I felt was necessary to understand this application.
__________________________________________ __________________________________________
Signature of Insured Date
Policy Owner (if not Insured)
_______________________________________________________
__________________________________________
Name Title
_______________________________________________________ __________________________________________
Signature Date
Question # Details of Conditions/Treatment Date & Duration Details and Degree of Recovery Doctors & Hospitals with Addresses
( Use additional sheets if needed)
PART II.
If “Yes” is answered for any of the following questions please provide full details in the space below. If there is not sucient space, please attach your answers on a separate sheet.
39. To the best of your knowledge and belief, are you in good health and free from any mental or physical impairment, except as
described in this application? q Yes q No - If No, please provide details:_____________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
40. Family history. Please complete the information in the grid below
Age if Living Age at Death Cause of Death Medical Conditions/History
Father
Mother
Siblings
32. Within the last 5 years have you had or been advised to have a surgical operation or hospitalization?
33. Have you ever received or requested benets or payments because of an injury or illness or disability?
34. Within the last 5 years have you had x-rays, electrocardiograms, blood studies, colonoscopy or other diagnostic tests?
35. Have you, a parent, or a sibling ever had diabetes, high blood pressure, heart disease, cancer or mental illness?
36. Within the last 5 years have you had any procedures, examination or tests recommended which have not
been completed?
37. Except as prescribed by a physician, have you ever used heroin, cocaine, codeine, barbiturates,
amphetamines, hallucinogens, or other drugs?
38. Within the last 5 years have you received medical treatment, attended a program or been counseled for
alcohol or drug abuse or been advised by a member of the medical profession to reduce the use of alcohol?
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
click to sign
signature
click to edit
click to sign
signature
click to edit
23929 Valencia Boulevard • Second Floor • Valencia, CA 91355
800.345.8816 toll-free • 661-254-0604 fax
www.piu.org • piu@piu.org
Authorization to Release Personal Information
I, the proposed insured, authorize all Healthcare Providers that have been involved in my care, diagnosis
or treatment including, but not limited to Physicians, Medical Practitioners, Hospitals, Clinics, Medically
related facilities, Rehabilitation facilities, Laboratories, Pharmacy, Insurance or Reinsurance Company,
or Consumer Reporting Agency, to disclose my medical records to Petersen International Underwriters, or
its assigned authorized agent/representative including, but not limited to: Secure Image Solutions, for the
purpose of insurance underwriting or claims administration.
For purposes of this authorization, medical records shall include all health information pertaining to any
medical history or physical condition and treatment received including, but not be limited to patient
histories, progress notes, test results, X-ray/laboratory and other reports, psychiatric evaluations, drug
and/or Alcohol Treatment, HIV Tests/Test Results, and any other pertinent medical information.
I understand and agree that Petersen International Underwriters may disclose my medical records and the
information contained in those records to third parties such as insurance companies or insurance
underwriters, attorneys, or to representatives of such third parties (including reinsurers and information
agencies) for the purpose as stated in the above. Additionally, it is understood that disclosure of medical
conditions as they relate to my insurability may be disclosed to persons with a direct insurable interest.
Medical or nancial information, as it aects my insurability or any claim, may also be discussed with my
insurance agent or broker. I also understand that when my medical records are disclosed pursuant to this
Authorization, my medical records and the information contained in those records may be subject to
re-disclosure by the recipient and may no longer be protected by Federal Privacy Laws.
I understand that I may revoke this Authorization, except to the extent that any health care provider or
Petersen International Underwriters, has acted in reliance upon this Authorization. My revocation of this
Authorization must be in writing to Petersen International Underwriters.
A copy of this signed Authorization is valid as the original. I have the right to a copy of this Authorization.
is Authorization will expire 2 years aer the date that I have signed this Authorization.
Signature of Proposed Insured Date
Date
Signature of Legal Representative
(if other than Proposed Insured)
*If the individual whose information is being disclosed is a minor, a parent or legal guardian must sign.
In Compliance with HIPAA & Financial Privacy Regulation
Proposed Insured Name Date of Birth
Legal Representative* Relationship
Email
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application For Disability Insurance (Oregon Home Care Commission Workforce)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 December 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document