OTHER INCOME QUESTIONNAIRE


In order to ensure that we are currently issuing the proper monthly benefit on your claim, we are requesting that you complete and return this form. Please list the gross monthly income you are currently receiving from the following sources. The sources of income documented below may or may not impact your benefit payment from Madison National Life Insurance. The determination regarding the impact of the other income documented below will be made upon receipt of this form and review of the terms of your policy.

We ask that you complete each box located below. If benefits have not been issued please indicate so by entering “$0.00” in the respective box. If you are receiving benefits please indicate the current benefit amount and the effective date of benefits. If benefits have been awarded but not previously reported to our company we also ask that you provide our company with copies of your award notification letter(s) or other official documents which show the history of your benefits over the course of your claim. These documents must be in the form of an official statement from the benefit provider.


Name (print):
Email Address:
Claim #:
Social Security Disability/Retirement Benefits:
Current Amount:

Effective Date:

Social Security Disability Dependent Benefits:
Current Amount:

Effective Date:

State Disability/Retirement Benefits:
Current Amount:

Effective Date:

Public Employees Disability/Retirement Benefits:
Current Amount:

Effective Date:

Teachers Disability/Retirement System Benefits:
Current Amount:

Effective Date:

Any other Disability/Retirement System Benefit (specify below):

Current Amount:

Effective Date:

Worker’s Compensation:
Current Amount:

Effective Date:

"No - fault" Automobile Insurance benefits:
Current Amount:

Effective Date:

Income from any settlement resulting from or related to your claimed disability:
Current Amount:

Effective Date:

Income from any type of employment including work for an employer or self employment (Please enclose paystubs, pay information, and contact information for your employer):
Current Amount:

Effective Date:

Any other type of income received as a result of sick pay, bonus pay, vacation pay, commission, any salary continuation plan and/or any other type of extra pay (specify below):
Current Amount:

Effective Date:

Any other sources of income (specify source of income below):

Current Amount:

Effective Date:


Current Amount:

Effective Date:


Current Amount:

Effective Date:

Notice to all persons completing this questionnaire: It is fraudulent to fill out this form with information you know to be false or to knowingly omit important facts. Criminal and/or civil penalties can result from such an act.

The information I have provided on this form is accurate to the best of my knowledge.
I have received and read the fraud warning statements provided with this form.
Signature: You will be prompted for your signature at a later date.
Date: The date will be filled upon receiving your signature.

Attach Files

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FRAUD WARNINGS

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance may be guilty of a crime and subject to fines, confinement in prison and/or denial of insurance benefits. This warning applies to the following states: Alabama, Alaska, Arkansas, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana, Iowa, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia, West Virginia, Wisconsin, Wyoming.
ARIZONA WARNING: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
CALIFORNIA WARNING: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
COLORADO WARNING: WARNING: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damage. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the Department of Regulatory Agencies.
DISTRICT OF COLUMBIA WARNING: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.
FLORIDA WARNING: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
GEORGIA WARNING: WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
KANSAS WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance may be guilty of fraud, as determined by a court of law, and subject to fines, confinement in prison and/or denial of insurance benefits.
KENTUCKY WARNING: WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
LOUISIANA WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance may be guilty of a crime and subject to fines, and confinement in prison.
MAINE WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MARYLAND WARNING: WARNING: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NEW HAMPSHIRE WARNING: WARNING: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
NEW JERSEY WARNING: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
NEW YORK WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
OREGON WARNING: WARNING: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer by submitting an application, or by filing a claim containing a false statement as to any material fact, may be violating state law.
PENNSYLVANIA WARNING: WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
TENNESSEE WARNING: WARNING: It is a crime to knowingly supply false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
WASHINGTON WARNING: WARNING: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
Signature: You will be prompted for your signature at a later date.
Date: The date will be filled upon receiving your signature.