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 - Stroke

P

When did applicant have his/her first stoke?

P

When did applicant have his/her last stoke?

P

Number of strokes in past 24 months?

none   1 2 or more

P

Has the applicant had carohd artery surgery as a result of a stroke?

Yes   No 
If Yes, enter month/year

P

Does applicant have any of the following residual neurological defects?

Slurred-speech    Loss of use of Limb
 Restricted use of Limb 
 Any other impairment (Explain below)

P

When did applicant have last EKG?

  within last 12 months    1 -2  years    2 plus years

P

What is applicants last  cholesterol reading?

P

What is applicants last  blood pressure reading?

P

 

 Does applicant exercise regularly 3 or more times/week?

  Yes    No
If Yes, explain type of exercise

P

List any other illness or impairments

P List any medications currently taken
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.