Reid Disability Advisors, LLC

Disability Insurance Intake Form

All the information we need to get you quotes from our partners.

Name

Phone

Date of Birth

mm/dd/yyyy

Gender

Are You a US Citizen?

Which US State Do You Live In?

Residency or Fellowship Program or Current Employer

Specify W2 or 1099 if you are already an attending physician.

Medical Specialty

What Year Will You Graduate? (if still in residency or fellowship)

Height

Weight

Tobacco Use

If yes, please be as specific as possible regarding frequency and type.

Please List ANY Medical Problems/Diagnoses That You Have * Required

Even previous diagnoses that you consider resolved (and when resolved).

Please List ANY Current or Prior Prescriptions That You Have Received * Required

Please include approximate start date and end date if no longer taking.

Please List ANY Upcoming Medical Procedures or Appointments

Annual or Well Patient Visits do not need to be included.

Do You Have Student Loans?

Current Annual Income

If you were referred by someone, please let us know who to thank!