Disability Insurance Application

SECTION 1: PERSONAL INFORMATION

Full Legal Name:

Date of Birth:

Social Security Number:

Home Address:

City:

State:

ZIP Code:

Phone (Home):

Phone (Mobile):

Email:

Marital Status:

Single

Married

Divorced

Widowed

Number of Dependents:

Spouse's Occupation:

SECTION 3: INCOME & FINANCIAL INFORMATION

Income Source	Current Year	Previous Year	Two Years Ago
Business Net Income (Schedule C or K-1)	$	$	$
W-2 Wages from Business	$	$	$
Other Business Income	$	$	$
Total Annual Income	$	$	$

Monthly Business Expenses

Expense Category	Monthly Amount	Critical During Disability?
Rent/Mortgage (Business Property)	$	Yes
Equipment Loans/Leases	$	Yes
Insurance Premiums	$	Yes
Utilities	$	Yes
Key Employee Salaries	$	Yes
Accounting/Legal Fees	$	Yes
Other Fixed Expenses	$	Yes
Total Monthly Overhead	$

Alliance Financial Planning Integration

Income Replacement Calculation: Based on your financial information, our Alliance planning tools will calculate optimal benefit amounts to maintain your standard of living during disability.

Business Expense Analysis: Our integrated platform will analyze your critical business expenses and recommend appropriate business overhead expense coverage limits.

SECTION 6: BUSINESS CONTINUITY PLANNING

Key Personnel who could manage business operations during your disability:

Name	Title/Role	Years with Company	Can Make Financial Decisions?
			Yes
			Yes
			Yes

Do you have existing business continuity plans or succession planning?

Yes

Partially developed

Would you need temporary management assistance during disability?

Yes

Recovery Support & Accommodation Resources

Vocational Rehabilitation: Alliance partners with leading rehabilitation specialists who understand the construction industry's unique demands and can help develop modified duty programs.

Workplace Accommodations: Access to ergonomic assessments, equipment modifications, and job restructuring guidance to facilitate your return to work.

Business Continuity Support: Our network includes interim management professionals and business consultants specializing in construction companies.

SECTION 7: EXISTING COVERAGE

Do you currently have any disability insurance coverage?

Yes

If yes, please provide details:

Insurance Company	Policy Type	Monthly Benefit	Elimination Period
		$

Have you ever been declined for disability insurance or had a policy canceled?

Yes - Please explain:

APPLICANT DECLARATION AND SIGNATURE

I declare that the statements made in this application are true and complete to the best of my knowledge and belief. I understand that any false statements or material omissions may void this application or any resulting policy. I authorize the release of medical and financial information necessary to process this application. I understand that coverage is not effective until the policy is issued and delivered, and the first premium is paid.

Applicant Signature:

Print Name:

Date:

Agent/Broker Signature:

Print Name:

License Number:

Date:

Required Documentation: Please attach copies of the following documents with your completed application:

Last 3 years of tax returns (including Schedule C or K-1)
Current year-to-date profit & loss statement
Business bank statements (last 3 months)
Current business license
Existing disability insurance policies (if applicable)

ALLIANCE FOR CONTRACTORS

Protecting Your Business, Securing Your Future

Application Form v2024.1 | For Office Use Only: App# __________ Date Received: __________

Disability Insurance Application

Business Owner Income Protection Coverage

Monthly Business Expenses