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https://app.smartsheet.com/b/form/8b14b6e61d08423c86c8faa73e993394?MassEmailID=377434502&email_id=13762&emailaddress=lrdfit...
Submission: On August 28 via manual from US — Scanned from DE
Submission: On August 28 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_First Name" data-client-type="text" id="epDMRD7r9" class="css-1e3khfm ef83ajd0"><label for="text_box_First Name" data-client-id="label_First Name" class="css-1xl1v40 ekxsfat0">First Name<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_First Name" data-testid="text_box_First Name" data-client-id="text_box_First Name" data-client-type="" name="epDMRD7r9" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Last Name" data-client-type="text" id="M8yObyAN6" class="css-1e3khfm ef83ajd0"><label for="text_box_Last Name" data-client-id="label_Last Name" class="css-1xl1v40 ekxsfat0">Last Name<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Last Name" data-testid="text_box_Last Name" data-client-id="text_box_Last Name" data-client-type="" name="M8yObyAN6" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_State" data-client-type="text" id="EPz1mzYy0" class="css-1e3khfm ef83ajd0"><label for="text_box_State" data-client-id="label_State" class="css-1xl1v40 ekxsfat0">State<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_State" data-testid="text_box_State" data-client-id="text_box_State" data-client-type="" name="EPz1mzYy0" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Employer/Agency" data-client-type="text" id="Pbj5MZ1A0" class="css-1e3khfm ef83ajd0"><label for="text_box_Employer/Agency" data-client-id="label_Employer/Agency" class="css-1xl1v40 ekxsfat0">Employer/Agency<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Employer/Agency" data-testid="text_box_Employer/Agency" data-client-id="text_box_Employer/Agency" data-client-type="" name="Pbj5MZ1A0" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Annual Base Pay" data-client-type="text" id="q8v7avm1X" class="css-1e3khfm ef83ajd0"><label for="text_box_Annual Base Pay" data-client-id="label_Annual Base Pay" class="css-1xl1v40 ekxsfat0">Annual Base Pay<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Annual Base Pay" data-testid="text_box_Annual Base Pay" data-client-id="text_box_Annual Base Pay" data-client-type="" name="q8v7avm1X" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Present Age" data-client-type="text" id="RObm5bYRO" class="css-1e3khfm ef83ajd0"><label for="text_box_Present Age" data-client-id="label_Present Age" class="css-1xl1v40 ekxsfat0">Present Age<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Present Age" data-testid="text_box_Present Age" data-client-id="text_box_Present Age" data-client-type="" name="RObm5bYRO" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Email address" data-client-type="text" id="GYo0zo98L" class="css-1e3khfm ef83ajd0"><label for="text_box_Email address" data-client-id="label_Email address" class="css-1xl1v40 ekxsfat0">Email address<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_Email_address" class="rich-text-field-desc">
<p>for us to send you information</p>
</div>
<div style="display: flex;"><input title="" aria-invalid="false" aria-describedby="description_Email_address" tabindex="0" id="text_box_Email address" data-testid="text_box_Email address" data-client-id="text_box_Email address"
data-client-type="" name="GYo0zo98L" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Phone number" data-client-type="text" id="oy3p0wWRL" class="css-1e3khfm ef83ajd0"><label for="text_box_Phone number" data-client-id="label_Phone number" class="css-1xl1v40 ekxsfat0">Phone number<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_Phone_number" class="rich-text-field-desc">
<p>to review coverage</p>
</div>
<div style="display: flex;"><input title="" aria-invalid="false" aria-describedby="description_Phone_number" tabindex="0" id="text_box_Phone number" data-testid="text_box_Phone number" data-client-id="text_box_Phone number" data-client-type=""
name="oy3p0wWRL" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="email_receipt_section">
<div data-client-id="container_email_receipt" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="email_receipt" class="css-1xs1ymt e14sboee2">
</div>
<div class="css-1gl0c9l excyp8g0"><label class="css-1y93uaa excyp8g1"><input data-client-id="email_receipt_checkbox" name="EMAIL_RECEIPT_CHECKBOX" type="checkbox" class="css-1czgm8r excyp8g2" value="false"><span>Send me a copy of my
responses</span></label></div>
</div>
</div>
<div class="css-1ock8o4 e1xpzprc2"><button data-client-id="form_submit_btn" disabled="" type="submit" value="submit" class="css-oltpmt e1xpzprc0"><span>Submit</span></button></div>
<div data-client-id="footer" class="css-ybae4b e8i4qwl0">
<div class="css-1kw6mnl e8i4qwl1"><a target="_blank" href="https://www.smartsheet.com/legal/privacy" rel="noopener noreferrer" data-client-id="footer_privacy" class="css-a7ff3e e8i4qwl2"><span>Privacy Notice</span></a><span
style="margin: 0px 5px;">|</span><a target="_blank" href="https://app.smartsheet.com/b/reportabuse?EQBCT=8b14b6e61d08423c86c8faa73e993394" rel="noopener noreferrer" data-client-id="footer_reportAbuse" class="css-a7ff3e e8i4qwl2"><span>Report Abuse</span></a>
</div>
</div>
</form>Text Content
Federal Disability Benefit Form Short-Term Disability Insurance is designed to help protect your paycheck. This policy provides temporary income protection for people who are unable to work. If you get injured or become sick, it’s important to protect your income. According to a 2020 survey by Life Happens, 63% of Americans would experience financial hardship after six months of no income. Some people would be affected much quicker – 14% would be impacted immediately. Let’s answer all the questions you have about short-term disability insurance First Name* Last Name* State* Employer/Agency* Annual Base Pay* Present Age* Email address* for us to send you information Phone number* to review coverage -------------------------------------------------------------------------------- Send me a copy of my responses Submit Privacy Notice|Report Abuse