Division or Union ID #   Railroad Company

# Full time Engineers   # Full time Conductors

1. Is there any underlying disability coverage in force other than RUIA? Yes No If so, please provide a copy of the plan.

2. Will this replace an existing plan?   If so, please provide the intended transition date: A copy of your current plan and bill is required for us to provide takeover benefits.

3. The following census information required to generate a quotation for you.  Would you like us to send you prepared census sheets for your use?  Yes No

4. Preferred method for salary verification required at time of claim:

  Pay stubs prior 3 months   W2 prior year    Payroll department confirmation

5. Please specify a contact person who is able to verify, by signature, the full time active employment status of a claimant.

Name    Title 

Address 

City    State    ZIP 

Telephone    Fax 

Cell    Email 

6. Billing contact and address for monthly list bill and invoice if other than above.