Checklist for Submitting a Completed App Long-Term Disability Insurance I Income Protection+

Sep 19, 2026

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Checklist for submitting a completed Long-Term Disability Insurance application under Income Protection+. Includes underwriting guidance to improve success, required income and tax documentation by applicant type (employees, self-employed/commissioned, and various business owners), and instructions for providing health history, doctor information, and paramedical exam requirements. Specifies non-medical limits and examination/urinalysis/blood requirement thresholds by age and monthly benefit amount, plus procedures for ordering interviews and contacting authorized paramedical firms. Includes producer-only and state availability notes.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Income Documentation

Employees

Businesses

Health History

Non-Medical Limits & Exam Requirements

Authorized Paramedical Firms

Personal History Interviews

Checklist for Submitting a Completed App Long-Term Disability Insurance I Income Protection+ Here are some tips from our Underwriting Department to help increase your success! We’re always available if you have questions at: 800-276-7619 Ext. 4264 or [underwriting@assurity.com](underwriting@assurity.com). Income Documentation Include the required income documentation indicated below with your client’s application. Employees Employee Only Monthly Benefit Amount Documents Needed | Not Self-Employed | $8,000 or less
More than $8,000 | None
ı 2 pay stubs, Federal Tax Form W-2 or
Federal Tax Return | | --- | --- | --- | | Self-Employed or Commissioned Salesperson | $6,000 or less
More than $6,000 and 1 Year,
2 Year, 5 Year, or 10 Year benefit period
More than $6,000 | None
ı Federal Tax Return with all schedules ı Federal Tax Form W-2
ı 2 years Federal Tax Returns with all schedules ı Federal Tax Form W-2 | Businesses Business Personal Documents Needed Business Documents Needed Sole Proprietor Farmer or Rancher Owner of C Corporation Owner of S Corporation Partner of Partnership ı Federal Tax Form 1040, including Schedule C ı Federal Tax Form 1040, including Schedule F ı Federal Tax Form W-2 ı Federal Tax Form W-2 ı Federal Tax Form 1040, including Schedule E, Part II ı Federal Tax Form 1040, including Schedule E, Part II None None ı Federal Corporate Tax Form 1120, including Schedule E ı Federal Corporate Tax Form 1120S, including Schedule K-1 ı Federal Partnership Tax Form 1065, including Schedule K-1 Health History Please use the Pre-Qualification Checklist if your client has any health history. Also, make sure to provide the doctor’s information with the application. Non-Medical Limits & Exam Requirements Age Monthly Benefit Amount Exam Paramedical Exam UA Urinalysis BLD Blood Requirements | 18-50 | $500- $10,000 $10,001 and above | No
Yes | No
Yes | No
Yes | | --- | --- | --- | --- | --- | | 51-64 | $500- $6,000
$6,001 and above | No
Yes | No
Yes | No
Yes | NOTE: These limits are subject to change at any time. Assurity reserves the right to require a medical exam and/or other medical requirements on any applicant. Authorized Paramedical Firms Our authorized paramedical firms have the examination forms, containers and blood draw kits in stock. For significant medical health histories or if the applicant has previously been declined, contact the Customer Connections prior to scheduling an examination. American Paraprofessional Systems, Inc. (APPS) Examination Management Services (EMSI) Quest Diagnostics – ExamOne Hooper Holmes Portamedic National Service Center 800-967-1499 800-872-3674 800-873-8845 800-765-1010 Personal History Interviews For applications with monthly benefits over $10,000, our team at Assurity will conduct a personal history interview with your client. An interview may be ordered on any benefit amount if necessary at the underwriter’s discretion. ı Inform your client that he/she may receive a phone call regarding a Personal Health Interview.ı If applicable, indicate your client’s time preference for the interview on the application. Assurity Interview Department: 877-611-4701 Monday – Thursday: 7 a. m – 8 p. m. CST Friday: 7 a. m.– 6 p. m. CST Saturday: 9 a. m.– 1 p. m. CST For complete details, please refer to Assurity’s Underwriting Guide on the Agent Center. FOR PRODUCER USE ONLY. NOT FOR USE WITH THE GENERAL PUBLIC. NOT AVAILABLE IN NEW YORK. Policy Form No. I H2401 underwritten by Assurity Life Insurance Company, Lincoln, Nebraska. Assurity is a marketing name for the mutual holding company Assurity Group, Inc. and its subsidiaries. Those subsidiaries include but are not limited to: Assurity Life Insurance Company and Assurity Life Insurance Company of New York. Insurance products and services are offered by Assurity Life Insurance Company

FAQs

What income documentation must be included with a client’s Income Protection+ application?

Include the required income documentation indicated in the checklist based on whether the applicant is an employee or self-employed/commissioned, or whether the applicant is part of different business structures.

When are paramedical exams and medical requirements required?

Exams and lab requirements depend on the applicant’s age and monthly benefit amount, with specified “No/Yes” determinations for paramedical exam, urinalysis (UA), and blood requirements (BLD).

What should producers do for applications with monthly benefits over $10,000?

Assurity conducts a personal history interview. Inform the client they may receive a phone call, and if applicable, record the client’s time preference on the application.

Sep 19, 2026

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