Prudential Group Disability Insurance – Education and Employment History Form (GL.2009.009, Ed. 06/2017) Instructions
This form contains 183 fields organized into 32 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Certificate/License Details | ||
| Certificate or Licenses Obtained | Text |
Enter the name or description of the certificate or license obtained.
|
| Expired Yes | Checkbox |
Check this box if the certification or license has expired.
|
| Expired No | Checkbox |
Check this box if the certification or license has not expired.
|
| Expiration Date Month | Date |
Enter the month of the expiration date.
|
| Expiration Date Day | Date |
Enter the day of the expiration date.
|
| Expiration Date Year | Date |
Enter the year of the expiration date.
|
| Claim Number | ||
| Claim Number | Text |
Enter the claim number related to this form.
|
| Claimant Name | ||
| Claimant First Name | Text |
Provide the first name of the claimant.
|
| Claimant Middle Initial | Text |
Provide the middle initial of the claimant.
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| Claimant Last Name | Text |
Provide the last name of the claimant.
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| College Training | ||
| College Training check yes or no | CheckBox | |
| College Training No | Checkbox |
Check this box if you do not have college training.
|
| College Training Degree Yes | Checkbox |
Check this box if you obtained a degree as part of your college training.
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| College Training Degree No | Checkbox |
Check this box if you did not obtain a degree as part of your college training.
|
| College Training Type | Text |
Enter the type of college training received, such as AAS or BA.
|
| College Training Location | Text |
Enter the location where the college training was received.
|
| College Training Completion Date | Text |
Enter the date or period when the college training was completed.
|
| College Training Years Completed | Text |
Enter the number of years completed for the college training.
|
| College Training Area of Concentration | Text |
Enter the area or areas of concentration for the college training.
|
| Computer Skills Checklist | ||
| Microsoft Word | Checkbox |
Check this box if you have used Microsoft Word at work and/or home.
|
| Microsoft Excel | Checkbox |
Check this box if you have used Microsoft Excel at work and/or home.
|
| Microsoft PowerPoint | Checkbox |
Check this box if you have used Microsoft PowerPoint at work and/or home.
|
| Internet Search | Checkbox |
Check this box if you have performed internet searches at work and/or home.
|
| Checkbox |
Check this box if you have used email at work and/or home.
|
|
| Database management | Checkbox |
Check this box if you have experience with database management at work and/or home.
|
| Computer graphics | Checkbox |
Check this box if you have used computer graphics software or tools at work and/or home.
|
| Any proprietary software at your employer(s) | Checkbox |
Check this box if you have used any proprietary software specific to your employer(s) at work and/or home.
|
| Date Signed | ||
| Signed Date Month | Text |
Enter the month the form was signed.
|
| Signed Date Day | Text |
Enter the day the form was signed.
|
| Signed Date Year | Text |
Enter the year the form was signed.
|
| Device Ownership and Usage | ||
| Own/Use Device - Yes | Checkbox |
Check this box if you own or use a computer, smartphone, or tablet/iPad.
|
| Own/Use Device - No | Checkbox |
Check this box if you do not own or use a computer, smartphone, or tablet/iPad.
|
| Purpose of Device Usage | Text |
Enter the specific uses for your computer, smartphone, tablet, or Kindle.
|
| Email Address | ||
| Email Address | Text |
Enter the user's email address.
|
| Employee Phone Number | ||
| Area Code | Text |
Provide the three-digit area code for the employee's phone number.
|
| Phone Number Prefix | Text |
Provide the three-digit prefix for the employee's phone number.
|
| Phone Number Line Number | Text |
Provide the four-digit line number for the employee's phone number.
|
| Employment Assistance Request | ||
| Yes, Employment Assistance Request | Checkbox |
Check this box if you would like assistance in locating suitable employment.
|
| No, Employment Assistance Request | Checkbox |
Check this box if you would not like assistance in locating suitable employment.
|
| First Prior Employment History | ||
| First Prior Employer Name | Text |
Please provide the name of the first prior employer.
|
| First Prior Employment Start Date | Date |
Please provide the start date of the first prior employment.
|
| First Prior Employment End Date | Date |
Please provide the end date of the first prior employment.
|
| First Prior Employment Job Title | Text |
Please provide the job title held during the first prior employment.
|
| First Prior Employment Annual Gross Salary | Number |
Please provide the annual gross salary for the first prior employment.
|
| First Prior Employment Reason for Leaving | Text |
Please provide the reason for leaving the first prior employment.
|
| First Prior Employment Tools Used Line 1 | Text |
Please describe the computers, tools, equipment, or materials used in the first prior employment.
|
| First Prior Employment Tools Used Line 2 | Text |
Please continue describing the computers, tools, equipment, or materials used in the first prior employment.
|
| First Prior Employment Job Duties Line 1 | Text |
Please describe in detail the job duties for the first prior employment, including any supervisory requirements.
|
| First Prior Employment Job Duties Line 2 | Text |
Please continue describing in detail the job duties for the first prior employment, including any supervisory requirements.
|
| First Prior Employment Certificate or License | Text |
Please provide any certificates or licenses required to perform the job for the first prior employment.
|
| General | ||
| specify reason leaving second row | Text | |
| specify Computers, Tools, Equipment and or material used in job row one | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| specify reason leaving second row | Text | |
| specify Computers, Tools, Equipment and or material used in job row one | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| specify reason leaving second row | Text | |
| specify Computers, Tools, Equipment and or material used in job row one | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| Describe job duties in detail - include any supervisory requirements | Text | |
| High School/GED Information | ||
| High School Highest Grade Completed | Text |
Enter the highest grade level you completed in high school.
|
| High School Graduation Date | Date |
Provide the date you graduated from high school.
|
| High School Course of Study | Text |
Specify your primary course of study or major during high school.
|
| GED Yes | Checkbox |
Check this box if you are not a high school graduate and you obtained your GED.
|
| GED No | Checkbox |
Check this box if you are not a high school graduate and you did not obtain your GED.
|
| GED Award Date | Date |
If you obtained a GED, provide the date it was awarded.
|
| Home Internet Access | ||
| Home Internet Access Yes | Checkbox |
Check this box if you can access the internet at home.
|
| Home Internet Access No | Checkbox |
Check this box if you cannot access the internet at home.
|
| Internet Navigation Ability | ||
| Can Navigate Internet - Yes | Checkbox |
Check this box if you can navigate the internet.
|
| Can Navigate Internet - No | Checkbox |
Check this box if you cannot navigate the internet.
|
| IT Certifications | ||
| IT Certification 1 | Text |
Please provide the name of an IT certification you possess.
|
| Job Search Details | ||
| Job Search Duration | Text |
Enter how long you have been actively searching for a job.
|
| Job Positions Sought | Text |
Enter the type of positions you have been seeking during your job search.
|
| Job Search Responses | Text |
Enter the kind of responses you have received regarding your job applications.
|
| Job-Seeking Resources | ||
| State Employment Service | Checkbox |
Check this box if you utilized a State Employment Service in your job-seeking efforts.
|
| State Vocational Rehabilitation | Checkbox |
Check this box if you utilized State Vocational Rehabilitation services in your job-seeking efforts.
|
| Internet Search | Checkbox |
Check this box if you utilized internet search engines or job boards in your job-seeking efforts.
|
| Friends | Checkbox |
Check this box if you relied on friends for assistance or leads in your job-seeking efforts.
|
| Want Ads | Checkbox |
Check this box if you utilized want ads (e.g., in newspapers or online classifieds) in your job-seeking efforts.
|
| Other | Checkbox |
Check this box if you utilized other resources not listed above in your job-seeking efforts and intend to provide an explanation.
|
| Other Job-Seeking Resource Explanation | Text |
Explain any other resources utilized for job-seeking that are not listed.
|
| License Activity Status | ||
| License Activity Description | Text |
Please describe what actions you have taken to keep your certification or license active.
|
| Military Services Training | ||
| Military Services Training Yes | Checkbox |
Check this box if you have received military services training.
|
| Military Services Training No | Checkbox |
Check this box if you have not received military services training.
|
| Military Services Training Type | Text |
Enter the type of military services training received.
|
| Military Services Training Location | Text |
Enter the location where the military services training was conducted.
|
| Military Services Training When | Text |
Enter when the military services training took place.
|
| Military Services Training Length | Text |
Enter the length of the military services training.
|
| Military Services Training Skill Usage | Text |
Describe how the skill acquired from the military services training was used.
|
| Mobile Phone Number | ||
| Mobile Phone Number - Part 1 | Text |
Enter the first three digits of your mobile phone number.
|
| Mobile Phone Number - Part 2 | Text |
Enter the next three digits of your mobile phone number.
|
| Mobile Phone Number - Part 3 | Text |
Enter the last four digits of your mobile phone number.
|
| Most Recent Employer Information | ||
| Most Recent Employer Name | Text |
Enter the full name of your most recent employer.
|
| Most Recent Employment Start Date | Text |
Provide the start date of your employment with your most recent employer.
|
| Most Recent Employment End Date | Text |
Provide the end date of your employment with your most recent employer.
|
| Most Recent Job Title | Text |
Enter your job title with your most recent employer.
|
| Most Recent Annual Gross Salary | Number |
Enter your annual gross salary from your most recent employer.
|
| Most Recent Reason for Leaving | Text |
Explain your reason for leaving your most recent employer.
|
| Most Recent Employer Additional Details | Text |
Provide any additional details or comments related to your most recent employer.
|
| Most Recent Job Equipment Used | Text |
List any computers, tools, equipment, or materials you used in your most recent job.
|
| Most Recent Job Duties | Text |
Describe your job duties in detail, including any supervisory requirements, for your most recent employer.
|
| Most Recent Job Duties Continued | Text |
Continue describing your job duties in detail, including any supervisory requirements, for your most recent employer.
|
| Most Recent Job Certificate or License | Text |
List any certificates or licenses required to perform your most recent job.
|
| Contacted Employer Regarding Return to Work - Yes | Checkbox |
Check this box if you have been in contact with your most recent employer regarding a return to work.
|
| Contacted Employer Regarding Return to Work - No | Checkbox |
Check this box if you have not been in contact with your most recent employer regarding a return to work.
|
| Employer Holding Job - Yes | Checkbox |
Check this box if your most recent employer is currently holding your job for you.
|
| Employer Holding Job - No | Checkbox |
Check this box if your most recent employer is not currently holding your job for you.
|
| Most Recent Job Hold Duration | Text |
State how long your most recent employer will hold your job.
|
| Discussed Alternate Jobs with Employer - Yes | Checkbox |
Check this box if you have discussed any alternate job opportunities with your most recent employer.
|
| Discussed Alternate Jobs with Employer - No | Checkbox |
Check this box if you have not discussed any alternate job opportunities with your most recent employer.
|
| Most Recent Return to Work Contact | Text |
Provide the name and phone number of the person you contacted regarding your return to work for your most recent employer.
|
| Other Training | ||
| Other Training 1 | Text |
Enter the first other training you have gained through work or other avenues, including any special designations obtained.
|
| Other Training 2 | Text |
Enter the second other training you have gained through work or other avenues, including any special designations obtained.
|
| Other Training 3 | Text |
Enter the third other training you have gained through work or other avenues, including any special designations obtained.
|
| Prior Employer 2 | ||
| Prior Employer 2 Name | Text |
Enter the name of your second prior employer.
|
| Prior Employer 2 Start Date | Date |
Enter the start date of your employment with the second prior employer.
|
| Prior Employer 2 End Date | Date |
Enter the end date of your employment with the second prior employer.
|
| Prior Employer 2 Job Title | Text |
Enter your job title at the second prior employer.
|
| Prior Employer 2 Annual Gross Salary | Number |
Enter your annual gross salary at the second prior employer.
|
| Prior Employer 2 Reason for Leaving | Text |
Enter the reason for leaving your second prior employer.
|
| Prior Employer 2 Additional Employment Details | Text |
Provide any additional details about your employment with the second prior employer.
|
| Prior Employer 2 Equipment Used Line 1 | Text |
Enter the computers, tools, equipment, or material used in your job at the second prior employer.
|
| Prior Employer 2 Equipment Used Line 2 | Text |
Continue entering the computers, tools, equipment, or material used in your job at the second prior employer.
|
| Prior Employer 2 Job Duties Line 1 | Text |
Describe your job duties in detail, including any supervisory requirements, for the second prior employer.
|
| Prior Employer 2 Job Duties Line 2 | Text |
Continue describing your job duties in detail, including any supervisory requirements, for the second prior employer.
|
| Prior Employer 2 Certificate or License | Text |
Enter any certificate or license required to perform your job at the second prior employer.
|
| Prior Employer 3 | ||
| Prior Employer 3 Name | Text |
Please provide the name of the third prior employer.
|
| Prior Employer 3 Dates From | Text |
Please provide the start date of employment for the third prior employer.
|
| Prior Employer 3 Dates To | Text |
Please provide the end date of employment for the third prior employer.
|
| Prior Employer 3 Job Title | Text |
Please provide your job title for the third prior employer.
|
| Prior Employer 3 Annual Gross Salary | Number |
Please provide your annual gross salary for the third prior employer.
|
| Prior Employer 3 Reason For Leaving | Text |
Please provide the reason for leaving the third prior employer.
|
| Prior Employer 3 Computers, Tools, Equipment Line 1 | Text |
Please describe the first line of computers, tools, equipment, and/or material used in your job with the third prior employer.
|
| Prior Employer 3 Computers, Tools, Equipment Line 2 | Text |
Please describe the second line of computers, tools, equipment, and/or material used in your job with the third prior employer.
|
| Prior Employer 3 Job Duties Line 1 | Text |
Please provide the first line of details regarding your job duties, including any supervisory requirements, for the third prior employer.
|
| Prior Employer 3 Job Duties Line 2 | Text |
Please provide the second line of details regarding your job duties, including any supervisory requirements, for the third prior employer.
|
| Prior Employer 3 Certificate/License | Text |
Please provide any certificate or license required to perform your job with the third prior employer.
|
| Prior Employer 4 | ||
| Prior Employer 4 Name of Employer | Text |
Enter the name of the fourth prior employer.
|
| Prior Employer 4 Employment Start Date | Date |
Enter the starting date of employment for the fourth prior employer.
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| Prior Employer 4 Employment End Date | Date |
Enter the ending date of employment for the fourth prior employer.
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| Prior Employer 4 Job Title | Text |
Enter your job title for the fourth prior employer.
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| Prior Employer 4 Annual Gross Salary | Number |
Enter your annual gross salary for the fourth prior employer.
|
| Prior Employer 4 Reason for Leaving | Text |
Enter the reason for leaving the fourth prior employer.
|
| Prior Employer 4 Reason for Leaving (Continued) | Text |
Provide additional details regarding the reason for leaving the fourth prior employer.
|
| Prior Employer 4 Tools/Equipment Used | Text |
Enter the computers, tools, equipment, and/or material used in the job for the fourth prior employer.
|
| Prior Employer 4 Tools/Equipment Used (Continued) | Text |
Provide additional details about the computers, tools, equipment, and/or material used in the job for the fourth prior employer.
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| Prior Employer 4 Job Duties | Text |
Describe the job duties in detail, including any supervisory requirements, for the fourth prior employer.
|
| Prior Employer 4 Job Duties (Continued) | Text |
Provide additional details about the job duties, including any supervisory requirements, for the fourth prior employer.
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| Prior Employer 4 Certificate/License | Text |
Enter any certificate or license required to perform the job for the fourth prior employer.
|
| Prior Employment History | ||
| Employer Name | Text |
Enter the name of the employer for this prior employment history entry.
|
| Employment Start Date | Date |
Enter the starting date of employment for this prior employment history entry.
|
| Employment End Date | Date |
Enter the ending date of employment for this prior employment history entry.
|
| Job Title | Text |
Enter the job title held during this prior employment history entry.
|
| Annual Gross Salary | Number |
Enter the annual gross salary received for this prior employment history entry.
|
| Reason for Leaving | Text |
Enter the reason for leaving this prior employment position.
|
| Additional Employment Details | Text |
Provide any additional relevant details regarding this prior employment history.
|
| Computers, Tools, Equipment Used | Text |
Describe the computers, tools, equipment, and/or material used in this prior job.
|
| Computers, Tools, Equipment Used (Continued) | Text |
Continue describing the computers, tools, equipment, and/or material used in this prior job.
|
| Job Duties Description | Text |
Describe the job duties in detail, including any supervisory requirements, for this prior employment position.
|
| Job Duties Description (Continued) | Text |
Continue describing the job duties in detail, including any supervisory requirements, for this prior employment position.
|
| Certificate/License Required | Text |
Enter any certificate or license required to perform this prior job.
|
| Social Media Usage | ||
| Social Media Usage: Yes | Checkbox |
Check this box if you use social media (e.g., Facebook, Twitter, etc.).
|
| Social Media Usage: No | Checkbox |
Check this box if you do not use social media (e.g., Facebook, Twitter, etc.).
|
| Social Media Platforms Used | Text |
Provide the names of the social media platforms you use.
|
| Typing Skills | ||
| Typing Skills Yes | Checkbox |
Check this box if you can keyboard or type.
|
| Typing Skills No | Checkbox |
Check this box if you cannot keyboard or type.
|
| Words Per Minute | Number |
Provide your typing speed in words per minute.
|
| Vocational Training | ||
| Vocational Training Type | Text |
Please provide the type of vocational training obtained.
|
| Vocational Training Location | Text |
Please provide the location where the vocational training was obtained.
|
| Vocational Training When | Text |
Please provide the date or period when the vocational training was completed.
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| Length of Vocational Training | Text |
Please provide the total length of the vocational training.
|
| Web Page Address | ||
| Web Page Address | Text |
Enter the web page address if applicable.
|
| Work Computer Usage | ||
| Work Computer Usage - Yes | Checkbox |
Check this box if you currently use or have previously used a computer at work.
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| Work Computer Usage - No | Checkbox |
Check this box if you do not currently use and have not previously used a computer at work.
|
| Work Computer Usage and Programs | Text |
Enter how you used your computer at work and list the programs you used.
|