Simplied Underwriting Application - 04-15-2019
IT IS UNDERSTOOD AND AGREED: 1. at all answers to the questions on this application, to the best of my knowledge and belief, are
complete and true; 2. at all answers on such questions, together with this agreement and any prior underwriting information, shall form the
basis of the issuance of any coverage hereunder; 3. at 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 benets shall be payable; 4. at except as amended by the answers to the above questions, any answer shown on any prior
application for this coverage signed and dated by me are expressly rearmed.
_________________________ __________ _____________________________________ ___________
Signature of Insured Date Signature of Policy Owner (if not Insured) Date
Simplied Underwriting Application
Insured:
Employer’s Name:
Occupation/Specialty:
Policy Owner Name:
Policy Owner Address:
Billing Address:
Email Address:
_______________________________________________ Date of Birth: ______________ Gender: _________
__________________________________________________________________________________________
_______________________________________________ Loss Payee: _________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________ Attention: __________________________________
_______________________________________________ Phone Number: ______________________________
1. What was your gross earned income less business expenses, but before taxes from your profession?
2. What was “other income” last year? (dividends, interest, rents, royalties, estates and trusts, etc. - circle items)
3. What was contributed to IRA, HR10, qualied pension or prot-sharing plan? (Is this included in Question #1?)
4. Have you been approved for a fully underwritten non-cancellable disability policy within the last
90 days? If “Yes” please include a copy of the declaration page. q Yes q No
5. Have you ever had life, health, or accident insurance declined, postponed, cancelled, rated, or modied,
or renewal or reinstatement of such insurance refused? If “Yes” please provide details below. q Yes q No
________________________________________________________________________________________________________
________________________________________________________________________________________________________
6. Please list all disability insurance (including group, individual, and salary continuation plans) you have in force, are applying for,
or are reinstating.
Monthly Benet Issue Date Insurer
7. Requested Benets
Monthly Benet requested: US$________________________
Elimination Period requested: q 90 Days q 180 Days
Benet Period requested: q 24 Months q 60 Months q 120 Months
Optional Riders: q Residual q COLA
Lump Sum Benet (if applicable) US$________________________
US$ ______________
US$ ______________
US$ ______________
23929 Valencia Boulevard, Second Floor, Valencia, CA 91355
P: (800) 345-8816 | E: piu@piu.org | F: (661) 254-0604
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