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Updated: 05/07/2004

 

Cancer Form
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 - Cancer

P

What is the type of malignancy or cancer?

  Bladder    Breast    Cervical    Hodgkin Disease


  Melanoma  (Indicate type and where located on body)


  Prostrate (Indicate results of most recent PSA test using Gleasons Grade)
  I    II    III    IV 


  Skin  (Indicate type and where located on body)

 

  Colon or rectal  (Indicate rating according to Dukes Scale)
  A1    B1    B    C1    C2    D

P

When did applicant have the cancer diagnosed

P

Stage of tumor or malignancy

  1    2    2A    2B    3    3A    4    5    Other

P

List all treatments undertaken

  Surgical removal of malignancy    Chemotherapy    Radiation therapy
   Hormonal (orchidectomy -Des Lupron)
 Other  Explain Below

P

When was last treatment received?

P

Has there been any evidence of recurring cancer?

  Yes    No

If Yes, enter month and year: 

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. 
 
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