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This is a basic questionnaire that will provide us with a global understanding of your situation. Upon receipt, our staff at PGY1 Financial Solutions Corp can customize a file and block out time to connect with you. Should you have any questions, please do not hesitate to give Jay Weinberg, CLU ChFC a call (609) 432-8862.

Client Questionnaire

First Name(Required)

Last Name(Required)

Personal Email(Required)

Business Email(Required)

Phone #:(Required)

How did you learn about us?(Required)

Occupation

1. What is your medical specialty?(Required)

2. Do you plan to be certified in multiple specialties? If yes, please specify.(Required)

3. Are you a student, resident, fellow or currently practicing?(Required)

4. If you are currently in training, what is the anticipated month/year of graduation?(Required)

5. What school/hospital/institution/employer are you currently affiliated with?(Required)

6. If you have a job lined up, what is the name of your upcoming employer?(Required)

7. When you are practicing, do you expect to be in an academic setting or a private practice setting?(Required)

8. What state do you currently live in?(Required)

9. What state or geographical area do you plan to practice in?(Required)

General/Medical

1. What is your date of birth?(Required)

2. What is your sex?(Required)

3. What is your height and weight?(Required)

4. Have you previously applied for Disability Insurance? If yes, please provide Application Date, Insurance Company & Agent Name(Required)

5. Please note that if you apply for a medically underwritten Disability Insurance Policy prior to securing a GSI Policy, you may not be eligible for that respective GSI Policy. Therefore, it may be in your best interest to secure a GSI Policy prior to exploring medically underwritten policies.(Required)

6. If you are interested in applying for a GSI Policy, (if one happens to be available at your institution) please enter Yes here and NA in Questions 7-10 below. GSI policies do not require health questions and overlook pre-existing conditions as well as hazardous activities.(Required)

7. Do you have any pre-existing medical/psychological conditions? If yes, please explain.(Required)

8. Have you had any surgeries in the past 10 years? If yes, please explain.(Required)

9. Do you currently take any medicine? If yes, please list and explain.(Required)

10. Have you been on any medications in the past 3 years (other than antibiotics)? If yes, please list and explain.(Required)

11. Have you used tobacco or nicotine products in past 12 months?(Required)

12. Are you in the military? If yes, active or reserves?(Required)

Student Loans/Debts

1. Do you have student loans? If yes, please list amount.(Required)

2. Are you hoping to be eligible for any loan forgiveness programs?(Required)

3. Are you single, married and/or have dependents?(Required)

4. If married, what does your spouse do for a living?(Required)

Would you like a recommendation for an Accountant?(Required)

Would you like a recommendation for an Employment Contract Attorney?(Required)

Would you like a recommendation for an Physician Home Mortgage Specialist?(Required)

Phone

This field is for validation purposes and should be left unchanged.