EAppsGSI

What percentage of the premium for the coverage you are applying for will be paid by your employer?

Who will pay the premiums

If any part of the premium will be paid by you, will it be paid with Pre-tax dollarsAfter-tax dollars

How would you like to pay the premiums?

Within the past ten years, have you had an injury or sickness which caused a loss of sight in both eyes, hearing in both ears, speech, or the use of both hands, both feet, or one hand and one foot, in their entirety? YesNo

If yes, provide details

Within the past ten years, have you received or are you currently receiving treatment, attention or advice from a member of the medical profession for memory loss or confusion, Alzheimer's disease, stroke, senility, dementia, loss of speech or comprehension of spoken language? YesNo

If yes, provide details

Do you need human assistance of any kind to perform every day activities such as bathing, continence, dressing, eating, using the toilet or transferring (for example, from the chair to your bed)? YesNo

If yes, provide details

Do you use any special medical equipment or appliances such as a wheelchair, pacemaker, oxygen tank, cane, catheter, or artificial limb? YesNo

If yes, provide details

Guaranteed Standard Issue (GSI) Disability Insurance Questionnaire

Financial Information

Personal Financial Information

Premiums

Enhanced Catastrophic and Severe Disability Benefit