Guaranteed Standard Issue (GSI) Disability Insurance Questionnaire

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The purpose of this form is to gather information to help complete a GSI application for disability insurance — it is not an official application. Once you have completed this form, your agent will use the information to prepare your formal e-Application, which requires your review and authorization before being submitted to the insurance company. A separate, secure link will be sent to you when completed. Your agent may reach out to you with questions.

Full Legal Name

Use the proposed insured name as it appears on legal documents.

Birth Information

Information about a proposed insured background

Gender

Proposed insured information

if no, provide your Visa Information:

Contact Details

Primary Address

Mailing address is primarily where the proposed insured receives mail, but does not live at the majority of the time

Fraud Statement

Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Jamie Fleischner, CLU®, ChFC®, LUTCF
(303) 358-8021
Email me

We value your privacy. Due to the confidential nature of the questions being asked, we limit the amount of time that we maintain your information. Once you complete the questionnaire, your answers are delivered securely to your agent, who will complete your official application and send to you securely for your review and signature.

Please call your agent, Jamie Fleischner, CLU®, ChFC®, LUTCF at (303) 358-8021 with any questions. Thank you for working with us on your coverage.

Questions for Jamie?

Disability Quotes is an independent agency authorized to offer products of The Guardian Life Insurance Company of America (Guardian), New York, NY and its subsidiaries, and is not an affiliate or subsidiary of Guardian. The Guardian Logo is a registered service mark of Guardian, used with permission.