17985dc 2026

The document is a Musculoskeletal Questionnaire Application Supplement from Standard Insurance Company, intended for individuals applying for disability insurance. It requests detailed information about the proposed insured's musculoskeletal health history over the past 10 years, including any injuries, treatments, surgeries, and medications. The form also inquires about recent work absences due to these conditions and includes a declaration of truthfulness regarding the provided information.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information in the 'Proposed Insured' section, including your birth date.
In the first question, provide details about any musculoskeletal issues you've experienced in the last 10 years. Include diagnoses and treatment received.
If applicable, indicate whether you have had surgery for these conditions and fill out the corresponding fields with dates and facility information.
Answer whether you have used any medications related to your conditions, specifying names, dosages, and prescribing professionals as needed.
Respond to the question regarding missed work days due to these conditions, providing specific dates if necessary.
Use the remarks section for any additional comments or details that may be relevant to your application.
Finally, review all entries for accuracy before signing and dating the form at the bottom.

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