Individual Short Term Disability Coverage

Capitas - Short-Term Disability Coverage Proposal

  • Producer Information

  • Client Information

  • (Net Income if Business Owner or Salary if Employee)
  • If less than 1 full tax year in business:
  • Short Term Case Design

    The 3 Month Benefit Period is not available for the following state(s): CT, IA, IL, NJ, VA.
  • Coverage InForce

    (Check all appropriate boxes)
    (Check all that apply)
  • Past 5 years. Medications taking? Height & Weight?