Basic Information
Gender	Please Select Male Female
Age	Please Select 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65+
State of Residence	Please Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Occupation	Please Select Abstractor Accountant - Other Accountant - W/4 Yr Accounting Degree Actuary - Other Administrative Assistant Advertising, Sales All other M.D. or D.O. specialties Allergist/Immunologist Anesthesiologist Anesthetist Appraiser Art Gallery Manager Artist - Commercial Artist, Graphic Designer Attorney Audiologist Auditor Biochemist - Office and Consulting Biologist - Office and Consulting Bookkeeper Botanist - Office and Consulting Buyer Cardiologist Cardiovascular Surgeon Chemist - Office and Consulting Claims Adjuster, Examiner - Office Duties Only Clergy College Professor ($50K Last 2yrs and Grad. Degree) Commercial Artist Computer, Consultant, Systems Analyst, Programmer - other Computer, Consultant, Systems Analyst, Programmer (earning over $70K) Computer, Operator Consultant (Computer) Consultant (Financial, Mgt, PR) Copy Writer Counselor - MSW Degree Dean Of College or University Dentist Dermatologist Dietician - Not Preparing Food Draftsman Education - Dept. Head ($50K Last 2 Yrs and Grad Degree) Education - Full College Prof ($50K Last 2 Yrs and Grad Degree) Education - Other Education Administrator Education - Principal ($50K Last 2 Yrs and Grad Degree) Education - Superintendent ($50K Last 2 Yrs and Grad Degree) Education - Teacher Of Academic or Commercial Subjects Electrophysiologist Emergency Room Physician Employment Recruiter Endocrinologist Endodontist Engineer - Field or Lab Duties (Chemical, Mechanical, Electrical) ENT Entertainment, Motion Picture - Director (not self employed) Entertainment, Motion Picture - Management (office only) Entertainment, Motion Picture - Producer (not self employed) Entertainment, Motion Picture - Talent Agent Executive ($30K Last 2yrs or 4yr College Deg) - Office Duties Only Executive ($45K Last 2yrs and 10+ EEs) - Office Duties Only Family Practice Physician Financial Planner ($30K Last 2yrs) Financial Planner (5+ Yrs Exp $75K Last 2yrs, Full-Time) Funeral Director - No Embalming Gastroenterologist General Practice Physician Geologist - Office and Consulting Geriatrician Government, Auditor Government, Immigration Official - Official Duties Only (earning over $75K last 2 yrs) Government, Interpreter Government, Librarian Government, Social Worker - Office Duties Only and MSW Government, Tax Agent/Auditor Graphic Designer Hedge Fund Manager Hematologist Immunologist Insurance Adjustor, Examiner - Office and Consulting Duties Only Insurance Agent - $30K Last 2 Yrs Insurance Agent - Full Time, 5+ Yrs Exp, $75K Last 2 Yrs Interior Designer - Office and Consult Duties - (4 Yr Interior Design Degree) Internist Interpreter Investment Banker (earning over $75,000) Investment Banker, other Jeweler - Sales, Administration Only Landscape Architect - No Manual Labor, 4yr Professional Degree, less than 20% field Landscape Architect - Other Legal Assistant Legal Secretary Librarian Lobbyist Magazine, Copywriter - Office Duties Only Magazine, Editor - Office Duties Only Magazine, Manager - Office Duties Only Magazine, Publisher - Office Duties Only Magazine, Writer - Office Duties Only Manager, Art Gallery Manufacturing, Designer Manufacturing, Draftsman Manufacturing, Sales Representative Manufacturing, Sales Representative - Earning over $75K Market Research Analyst Minister Mortgage Loan Originator Mortician - Not Embalming Neonatologist Nephrologist Neurologist Neurosurgeon Newspaper, Copywriter - Office Duties Only Newspaper, Editor - Office Duties Only Newspaper, Manager - Office Duties Only Newspaper, Publisher - Office Duties Only Newspaper, Writer - Office Duties Only Nurse Anethetist Nurse Practitioner - Not Functioning As An RN Nursing Director Nursing Instructor Nutritionist - Not Preparing Food Obstetrician/Gynecologist Office Worker (Earning over $30K) Oncologist Ophthalmologist Opthalmologist Optician - Not Grinding Lenses Optometrist Oral Surgeon Orthodontist Orthopedic Surgeon Orthopedist Otolaryngologist Otologist Pain Management Physician Paralegal Pastor Pathologist Pediatrician Perfusionist Periodontist Physiatrist (Physical Medicine, Rehab) Physician - Other Physicians Assistant Physicist - Office and Consulting Plastic Surgeon Podiatrist Principal ($50K Last 2 Yrs and Grad Degree) Psychiatrist Psychologist - Other Graduate Degree Psychologist - Phd Degree Pulmonologist Purchasing Agent Rabbi - Synagogue Only Radio, Director (not self employed) Radio, Producer (not self employed) Radio, Station Manager Radiologist - All other states Radiologist; not performing invasive or interventional procedures Radiologist; performing invasive or interventional procedures Real Estate Appraiser Real Estate Property Manager (earning over $50K for last 2yrs) - no manual or maintenance duties Recruiter (Employment) Respiratory Therapist Rheumatologist Sales Manager - Earning Over 75K Sales Manager - Other Sales, Bond Trader Sales, Broker (Full Time, 5+ Yrs, $50K Last 2 Yrs) Sales, Insurance Agent ($30K Last 2 Yrs) Sales, Insurance Agent (Full Time, 5+ Yrs, $75K Last 2 Yrs) Sales, Manufacturers Representative - Earning over 75K Sales, Manufacturers Representative - Other Sales, Real Estate Agent, Broker, Developer (Full Time, Active for 4 Yrs and 50K Last 2 Yrs) Scientist - Office and Consulting Secretary Social Worker - Office Duty Only and MSW Speech Therapist Stockbroker ($30K Last 2 Yrs) Stockbroker (5+ Yrs Exp, $75K Last 2 Yrs) Superintendent ($50K Last 2 Yrs and Grad Degree) Surgeon Surgeon (all specialties) Tax Agent, Auditor Teacher, Choir Director Teacher, Driver Education Teacher, Guidance Counselor Teacher, Private Music Instructor Teacher, Special Education Television, Director Television, Producer Television, Station Manager Theater, Director (not self employed) Theater, Producer (not self employed) Urologist Venture Capitalist Veterinarian - Other Veterinarian - Small Animal, in Clinic Writer - Not Free Lance or Working From Home
Smoker?	No Yes
Annual Income	15,000 16,000 18,000 20,000 24,000 30,000 36,000 40,000 48,000 50,000 52,000 60,000 70,000 80,000 90,000 100,000 110,000 120,000 130,000 140,000 150,000 160,000 170,000 180,000 190,000 200,000 210,000 220,000 230,000 240,000 250,000 260,000 270,000 280,000 290,000 300,000 310,000 320,000 330,000 340,000 350,000 360,000 370,000 380,000 390,000 400,000 420,000 440,000 460,000 480,000 500,000 520,000 540,000 560,000 580,000 600,000 620,000 640,000 660,000 680,000 700,000 720,000 740,000 760,000 780,000 800,000 820,000 840,000 860,000 880,000 900,000 920,000 940,000 960,000 980,000 1,000,000 1,020,000 1,040,000 1,060,000 1,080,000 1,100,000 1,120,000 1,140,000 1,160,000 1,180,000 1,200,000 1,220,000 1,240,000 1,260,000 1,280,000 1,300,000 1,320,000 1,340,000 1,360,000 1,380,000 1,400,000 1,420,000 1,440,000 1,460,000 1,480,000 1,500,000 1,520,000 1,540,000 1,560,000
Existing Monthly Disability Income

• If you are residually disabled (under the terms of this rider) and lose at least 20% of your prior earnings, you receive a benefit that is proportionate to your loss of earnings. A residual disability is when you are not totally disabled, but solely due to an injury or sickness, you are able to perform some, but not all of the substantial and material duties of your occupation, unable to work full time in your occupation, or are working in another occupation.

• Once you qualify for residual disability benefits, you are guaranteed a minimum benefit of 50% of your maximum monthly benefit for the first six months. If your loss of earnings exceeds 75%, then 100% of the maximum benefit is paid.

• After recovering from a residual or total disability in which you were receiving benefits, and you return to work fulltime, recovery benefits are payable as long as you continue to have a recovery loss of earnings equal to or greater than 20% of your recovery prior earnings and the loss is directly and solely due to the injury or sickness that caused your prior disability. Recovery benefits end when you no longer have a recovery loss of earnings greater than 20% for two consecutive months and will not be paid beyond the maximum benefit period.

If you become totally disabled from your occupation and choose to work in another occupation, you’ll receive full benefits, regardless of the income you earn from the other occupation.