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 - Heart Disease

P

Age of diagnosis?

P

Has your client had a heart attack?

Yes   No 

P

Does your client have symptoms? Chest pain, shortness of breath, fatigue, etc.?

Yes   No 

P

What treatments has your client had in the past 5 years?

Angioplasty    Bypass Surgery Medical Mgt  
 Other  Explain Below

P

How many vessels were involved in your clients last treatment?

P

What was the date of your client's last stress test and doctor visit?

P

Are risk factors being modified? Cholesterol, blood pressure, smoking, build, regular exercise?

  Cholesterol  Blood Pressure    Smoking 
Exercise     Other  Explain Below
  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.