Group Disability Application
GOLD – Group Short/Long Term Disability Program
DIRECTIONS: This form must be completed to apply for Group Disability Coverage. When evidence of insurability is required, that form will be provided separately. To apply for coverage (as a Member read the notice(s) on back page of application; then complete all items, sign and date below.
When finished send to WPOA Representative who will submit it to Myers-Stevens & Toohey & Co., Inc. Keep a copy for your records.
Myers-Stevens & Toohey & Co., Inc. / 26101 Marguerite Parkway / Mission Viejo / CA 92692
Phone: 800-827-4695 / porac@MYERS-STEVENS.COM / License #0425842