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
  Height
  Weight
  Smoker?   Yes    No
  Other Insurance Company Actions   Rated Table    Postponed    Declined
If Rated Table, Enter information here:

Applicant Background - Foreign Travel

P

Answer questions on here if your applicant is a US citizen

Assuming the applicant currently or is planning to travel outside the US, please answer the following:

 

Which countries and cities do you plan to visit?

 

What is the purpose of the travel?
 Business    Pleasure Other 

Explain Other Here



How often does applicant plan to travel?

 

Average period of time for each trip?

 

When was last trip?

P

Answer questions here if your applicant is NOT a US citizen

How long has applicant been in the US?

 

What is the applicants Alien Registration Card (green card) number?

 

If applicant does not have a Alien Registration Card, what type of visa do they have?
    Enter Expiration Date: 

 

Does applicant own a home in the US?
 Yes   No 

If Yes enter address

 

Does applicant own a home in a foreign country?
 Yes   No 

 

If applicant is married, does family live with him/her?

Yes   No 
 

P

Has applicant ever been convicted of a crime in another country, including traffic violations or are there any criminal charges currently pending against them?

Yes   No 

If Yes please explain

P

What is your applicant's business address?

P

What is your applicants duties at the business?

  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.