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Ameritas COM Disability Form

This is NOT the application.

Completing the following form gives us the information to be able to send you an application for the College of Medicine Guaranteed Standard Issue long term disability program. It is not the application, we will send you the application by e-mail, and until you sign that you have not applied.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Guaranteed Issue Disability programs

Select Medical Residency Programs:*

Florida State College of Medicine Guaranteed Issue Insurance program

Ohio State University College of Medicine Guaranteed Issue Insurance program

1. Proposed Insured Personal Information

Name*

First Middle Last

Date of Birth:*

Gender (at birth):*

Female

Male

State of Birth (or Country if other than USA):*

Last 4 of Social Security Number*

Preferred Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone Number to use for e-apply:*

Preferred Email Address to use for e-apply:*

Are you a U.S. citizen or permanent resident?

YES

If "No," Citizenship:

Visa Type:

In the past 12 months, have you used any tobacco or nicotine products, and/or nicotine delivery systems?*

(such as cigarettes, cigars, cigarillos, vape, e-cigarettes, pipe, chewing tobacco, nicotine patches, nicotine gum)

YES

If "Yes," list type and frequency:

In the past 6 months, have you received disability benefits from any source, or do you currently have a claim for disability benefits pending?*

YES

2. Employment Information

Do you already have your post-graduation employment contract?*

YES

3. Existing Insurance

In the past 60 months, have you been declined or postponed for disability insurance?*

YES

Do you already have any existing Long Term Disability (group or individual)?*

YES

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2426 Bee Ridge Rd Suite B, Sarasota FL, 34239.
941-957-1310
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Executive Benefit Plans
Long Term Care
Disability Insurance

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