Application For Disability Insurance Benefit printable pdf download

Principal Life

Application for Disability Insurance

Insurance Company

P.O. Box 14455

Benefit Update Offer/

Des Moines, IA 50306-3455

Future Benefit Increase Offer

1. Name of Insured

Policy Number

2. Employer

Occupation/Duties

3. Report past income as shown on Federal Income Tax Return.

Earned Income:

Year to Date

Actual Last Year

a. Salary, Wages, Commissions & Bonus (W-2 and/or 1099 Form)

b. Sole-Proprietor (Net income on Form 1040, Schedule C)

c. Partner or member of Limited Liability Company (LLC)

(Schedule K-1 or Form 1040, Schedule E)

d. Owner of S-Corp or C-Corp (Schedule K-1 or Form 1040,

Schedule E, or Pro rata share of C-Corp net profits per Form 1120)

e. Pension and Profit Sharing Contributions

4. Unearned Income – Includes capital gains, interest, dividends, net rental income, pensions, annuities, and alimony.

Is unearned income greater than 10% of earned income, or $30,000?.................................................

Yes

If Yes, itemize:

5. Net Worth – Is net worth, excluding primary residence, greater than $6,000,000?..............................

Yes

If Yes, itemize:

6. Premium Payor

a. Premium paid by:

Insured

Employer

b. If your employer pays any part of the premium, is it reportable by you as taxable income? ............

Yes

7. Other Coverage – Do you have any other Disability Coverage in force other than this policy?...........

Yes

If yes, please describe all disability coverage in force, other than this policy. Indicate if it is: A) Individual,

B) Association, C) Group, D) Salary Continuation, E) Overhead Expense, or F) Buy-Out. Please include coverage

for which you will become eligible in the next 3 years after a qualifying period of employment has been met.

Type

Monthly Benefit

Elim.

Benefit

Will Coverage

Effective Date

Company or Source

(A, B, C, etc.)

Amount

Period

Be Replaced?

of Cancellation

Yes

Authorization

I represent that all statements in this application are true and complete to the best of my knowledge and belief. I have

submitted no money with this application. I understand that the statements in this application are the basis of this Benefit

Update Offer/Future Benefit Increase Offer. I have received a copy of “Notice of Insurance Information Practices”. It

includes notice required by any Fair Credit Reporting Act and describes Medical Information Bureau, Inc. (MIB, Inc.). I

authorize the release of any records or knowledge of me from any insurance company, institution, person, organization,

or MIB, Inc. to the Principal Life Insurance Company and/or its reinsurers. This authorization shall be valid for 24 months

from the date of this application. A copy of this authorization shall be as valid as the original.

Warning: It is a crime to provide false, misleading, or incomplete information to an insurance company for the purpose of

defrauding the company or any other person. Penalties include imprisonment and/or fines and denial of insurance benefits.

Signature and Title of Owner (if other than Insured)

Signature of Insured

Signed at: City

State

Date

AA 2300-1

Application For Disability Insurance Benefit

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