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NAPFA DISABILITY INSURANCE APPLICATION
Please complete the entire form to apply. All fields must be completed to submit.
All information provided on this information sheet is confidential and will be used solely for the purpose of plan enrollment.
Please add *john_ryan@ryan-insurance.net to your address book or "safe list" to ensure emails are received.
*Please note new email address
What is your name?
First Name
Last Name
What is the company name? Company Name
What is your work phone number?
Work Phone
What is your email address?
Email Address
What is your home address?
Street
City
State
Zip
What is the date of original NAPFA Membership?
Date of NAPFA Membership
OR Date of Hire by NAPFA Member?(Please answer only applicable question)
Date of Hire
Name of your NAPFA member employer
Name
What is your date of birth?
DOB
What is your age?
Age
Do not include renewal commissions in net monthly earnings.

What are your average monthly earnings?
Definitions of Monthly Earnings - click here
Net Monthly Earnings
Click Here ->  
Monthly Benefit
Monthly Annuity Contribution Benefit
Monthly Assisted Living Benefit
This will be your monthly premium deduction:
Do not send premium with application.
What is your gender?
Gender
 Male
Female
What is your Social Security #?
SSN
Are you a:
What is your job title?
Job Title
How many hours are worked a week?
Hrs. Worked/wk
(min. 20/hrs.required)
How did you hear about the NAPFA plan?
If other, please describe:
BANK DRAFT AUTHORIZATION
I (we) hereby authorize Ryan Insurance Strategy Consultants to initiate a debit entry to my (our) checking/savings account at the Financial Institution indicated below, on or about the 1st of each month, and initiate adjustments (if necessary) for any transactions credited/debited in error. This authority will remain in effect until Ryan Insurance Strategy Consultants is notified by me (us) in writing to cancel it in such time as to afford Ryan Insurance Strategy Consultants and my (our) Financial Institution a reasonable opportunity to act on it. A $10.00 charge to your account will be made in the event that Ryan Insurance Strategy Consultants' attempted withdrawal of premium is rejected for non-sufficient funds or because the account is closed without prior notification from you.
Banking Information:
Name of Banking Institution
City
State
Routing/Transit #
(Look between symbols "/: /:" on your check. This is a 9 digit number)
View Example
Checking Account
Savings Account
 #
Name(s) on the Bank Account:
Name 1
Name 2
I accept the terms of this Bank Draft Authorization.
*Information is Encrypted upon submission
You may also Fax or Mail these forms to us at:
John Ryan, CFP®
Ryan Insurance Strategy Consultants
5690 DTC Boulevard
Suite 130-W
Greenwood Village, CO 80111
Fax 888-337-2291
Please keep a copy of this calculation for your records.
("Print" option is not available once "Submit Form" button is selected)