My Protection Plus

What if your paychecks stopped? You’re suddenly unable to work due to an injury or illness. What’s next?

Think About It

Your income supports it all – your home, car, groceries, life insurance, retirement savings, and future plans. When a disability strikes, life can change in an instant. Medical expenses grow. Family life is disrupted. Your savings and retirement funds are at risk. They could be depleted quickly in order to keep the bills paid while you recover. Get Quotes

How It Works

It's simple. You make two choices - the monthly benefit amount you'll need and how long you will need it - which is called the benefit period. The options you choose can help you keep the cost within your budget.

This benefit period is the maximum number of months your policy will pay a benefit to you. Think about how long you would need to receive monthly benefits if you were unable to work due to injury or illness. This should be the benefit period you choose.

How It Pays

You’ll receive monthly benefits after a specific waiting period. The waiting period depends on the options you choose and whether you are unable to work due to an accident or an illness.

Short Term Protection

Priority Income Protection - Premium Calculator

Application for Individual Disability Income Insurance

Proposed Insured Information

First Name

Middle Name

Last Name

Your Gender

Female Male

Street Address

Street Address 2

City

State

Zip code

Mailing Address (if different from above)

Telephone Number

Full Name of Beneficiary

Relationship to Proposed Insured

* required field

Occupational / Financial Information

Occupation

Annual Income (If self-employed, use taxable net income)

For the last 6 months, have you been continuously at work for at least 30 hours per week with your current employer performing all the duties of your occupation?

Yes No

For the last 6 months, have you worked entirely in an office (administrative) setting?

Yes No

Are you currently in the process of filing or had a bankruptcy discharge in the last 2 years?

Yes No

Do you have other disability coverage that will remain in force, which when combined with this applied for coverage, will exceed 70 percent of your annual earned income?

Yes No

Is the coverage applied for replacing any existing coverage for the Proposed Insured? If "Yes," please give details below.

Yes No

* required field

Underwriting Information

Are you a U.S. Citizen or a Permanent Resident Card holder who has resided in the U.S. for 3 or more years?

Yes No

During the last 12months, have you used any form of tobacco or any form of nicotine replacement/cessation product (such as nicotine gum, patch, spray, ecig. and vapor)?

Yes No

Height/Weight

(Ft) (In) (Lbs)

Are you pregnant?

Yes No

During the last 12 months, other than for childbirth, have you been admitted to a hospital?

Yes No

During the last 12 months, other than for childbirth, have you had surgery, received, or been advised by a member of the medical profession to receive physical or occupational therapy?

Yes No

During the last 12 months, other than for childbirth, have you had 2 or more blood pressure readings over 140/90 taken by a member of the medical profession?

Yes No

During the last 2 years, have you been advised by a medical professional to undergo treatment, surgery, procedure, diagnostic evaluation or testing that has not yet been completed or diagnostic tests performed where the results are still pending or were inconclusive?

Yes No

During the last 2 years, have you used marijuana in any form for recreational or medical purposes?

Yes No

During the last 5 years, have you used narcotics in any form for recreational or medical purposes, cocaine, hallucinogens, barbiturates or other drugs?

Yes No

During the last 5 years, have you been declined for any disability or life insurance policy?

Yes No

During the last 5 years, have you applied for or received disability benefits?

Yes No

During the last 5 years, have you plead guilty to or been convicted of a felony, driving under the influence of alcohol or drugs, been incarcerated or currently on probation or parole?

Yes No

During the last 5 years, have you been treated for alcohol use?

Yes No

During the last 5 years, have you been diagnosed with or treated for Human Immunodeficiency Syndrome (HIV) / Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?

Yes No

* required field

Underwriting Information Part 2

During the last 5 years, have you been diagnosed with, received care or treatment, or been advised by a member of the medical profession to seek treatment for or consulted with a health care provider regarding:

Manic Depressive Illness (Bipolar), schizophrenia, Post Traumatic Stress Disorder (PTSD)?

Yes No

Brain or nerve system disease or disorder, including but not limited to, epilepsy, concussion syndrome (Traumatic Brain Injury), Dementia, Alzheimers, Multiple Sclerosis, Parkinson’s, Amyotrophic Lateral Sclerosis (ALS), neuropathy or stroke?

Yes No

Heart or artery disease, disorder or surgery?

Yes No

Lung disease or disorder, including but not limited to, chronic bronchitis, emphysema or severe sleep apnea?

Yes No

Leukemia, lymphoma, melanoma (except basal cell skin cancer) or any other cancer?

Yes No

Musculoskeletal disease or disorder, including but not limited to, fibromyalgia, chronic fatigue, rheumatoid or psoriatic arthritis?

Yes No

Treatment or surgery of the spine, neck, back, hip, knee or shoulder?

Yes No

Inflammatory bowel disease, including but not limited to, Crohn’s or ulcerative colitis?

Yes No

Chronic kidney disease?

Yes No

Liver disease, including but not limited to, cirrhosis, hepatitis B or C?

Yes No

Organ transplant?

Yes No

Diabetes?

Yes No

Connective tissue disease or disorder including, but not limited to, Systemic Lupus Erythematosus (SLE), scleroderma or polymyositis?

Yes No

Blood disease or disorder, including but not limited to, sickle cell anemia or blood clotting disorder?

Yes No

Birth Date

Birth State

* required field

What if your paychecks stopped? You’re suddenly unable to work due to an injury or illness. What’s next?

Think About It

How It Works

How It Pays

Priority Income Protection - Premium Calculator

Application for Individual Disability Income Insurance

Proposed Insured Information

Occupational / Financial Information

Underwriting Information

Underwriting Information Part 2

Contact Information

Sample Contract

Company	Policy Number	Monthly Benefit Amount