Integrated WealthCare
Disability Insurance Health Statement

Basic Information

Contact Information

Telephone Interview- if more information is needed, a representative may call you. Please provide the most convenient time and contact number for such a call weekdays between the hours of 9:00 a.m. and 9:00 p.m.

Occupational Information

Job Transition Information (Plans Following Residency)

Proposed Insured Questionnaire

Proposed Insured- Health History

In the past ten years, have you had, been treated for or received a consultation or counseling for:

Remarks and Special Requests

Other Disability Insurance Coverage of the Proposed Insured

Do not list current housestaff benefits. Do include any benefit that you will become eligible for within the the next six months through a new practice.

Category                       Status
IND = Individual           I = Inforce
P = Practice                   AP = Applied For, or Date of Eligibility (If future practice)