Complete each of the questions p

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 - Hepatitis C

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.

P	When was Hepatitis C diagnosed?
P	How was it contracted?	IV Drugs Blood Transfusion Tattoo Other Explain Below
P	Has there ever been a work-up with a gastroenterologist?	Yes No If Yes, Explain Below
P	Was a liver biopsy done?	Yes No If Yes, then check results that apply Inflammation Fibrosis Cirrhosis Other If possible, try to obtain pathology report from liver biopsy.
P	Identify any treatments used, date performed and results.	Interferon Rebetron Peg-interferon Other If Other Explain Below When was Treatment Done Successful in eliminating the virus? Yes No
P	How much alcohol does the applicant drink?
	Other Information