Complete each of the questions provided below.  Those questions with a P are required entries in order to process your application.  When all of the questions are complete select SUBMIT to complete the process.  We will contact you as soon as possible.
 

Applicant Contact Information

P

Applicant's Name

P State of Residence
P Applicants Date of Birth
P Sex   Male    Female
P Height
P Weight
P Smoker?   Yes    No
P Other Insurance Company Actions   Rated Table    Postponed    Declined
If Rated Table, Enter information here:

Applicant Health Background - Depression

P

Which has applicant been diagnosed as having?

  Depression     Manic Depressive (Bipolar)
 

P

Has applicant attempted suicide?

Yes   No 
If Yes, enter date

P

Has applicant been hospitalized for depression?

Yes   No 

P

Has applicant lost work due to depression?

Yes    No

P

Is applicant currently taking medication for depression?

P

Is applicant currently seeing a mental health therapist?

Yes   No 
If Yes, enter date of last visit

P

List any other illness or injury of applicant

P List all medications currently being used by applicant
P Has either parent or any brother/ sister died before age 65, other than by accident?   Yes    No
If Yes, explain:
  Other Information

Agent Information
P Agent Name
P Agency Name
P Address
P City
P State
P Phone
P Email
P Fax number
  Other Comments

Consolidated Insured Benefits Quotation Policy  After filling out the necessary information on this form you will receive a quote via phone or email and then have the option of applying for the actual overage. There is no commitment for filling out the information on this form and receiving a quote.