Integrated WealthCare Disability Insurance QuestionnaireBasic Information First Name MI Last Name SexMaleFemale Date of Birth What state do you currently live in? Email Address Preferred Contact Number How did you hear about Integrated WealthCare? What is your medical specialty? At what institution are you completing your training? What is your current PGY status? Are you currently moonlighting? YesNo Will you complete your training within the next 12 months? YesNo Do you have a signed contract?YesNo Will you be working forHospitalIndependent ContractorPrivate Group If you will be working for a hospital, please provide the name of your employer What will your starting salary be? Will you have long term disability benefits through your practice?YesNo Will you be moving to a new state?YesNo What is your anticipated date of transition? During Medical School, residency or fellowship did you have any documented visits for stress, emotional trauma or other psychiatric evaluation?YesNo Are you currently taking any anti-depressant medication?YesNo Do you currently use, or have you ever used, tobacco products (including cigars, chewing tobacco and marijuana)?YesNo Do you have any bone or joint disorders that may be seen as medically relevant to an insurance company?YesNo Plan Specifics: what is most important to you today? How do you prefer to make your payments?AnnuallySemi-AnnuallyMonthly (auto bank draft) Please provide any other data you feel is relevant or helpful to providing you the best solution. Contact Information
