Allstate Postal Disability Insurance Application

First Name

Middle Initial

Last Name

Cell Number

Date of Birth

Gender

Male

Female

SS#

Job Title

Address

Street Address City State ZIP Code

Month/year you started with USPS

Mother's Maiden Name

Annual Salary

Monthly Benefit Amount

Waiting Period (14 or 30 days)

Beneficiary Name

Beneficiary Relationship To You

Beneficiary DOB

Have questions? You can text or call Andrew at
636-219-6931

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AllState Rates

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