Long-Term Disability Census Form

  • Individual Census Form

    This is not an application for insurance. Please submit a separate census form for each person requesting a proposal.
  • (This includes any salary, wages, commissions, bonuses, and fees regularly earned for services performed by the insured)
  • (Benefit not to exceed 60% of Gross Annual Income to a maximum of $8,000 per month)
  • Optional Benefits

  • (Benefit not to exceed 40% of Gross Annual Income to a maximum of $3,200 per month)