Your Logo Here

Home | CIB Enrollment | FAQ | Industry Links | Contact | Site Map


864.271.6863     Office
800.922.7306 Toll Free
864.235.1892        Fax

Consolidated Insured Benefits
Individual Medical
Life Insurance
Annuities
Long Term Care
Short Term Medical
International Medical
Disability
Impaired Risk
About CIB

 

 

 

Diabetes Form
Coronary Artery Form
Alcohol Form
Driving Violations
HepatitisC Form
Cancer Form
Stroke Form
Drug Usage
Depression Form
Foreign Travel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Updated: 05/07/2004

 

Depression 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 - Depression

P

Which has applicant been diagnosed as having?

  Depression     Manic Depressive (Bipolar)
 

P

Has applicant attempted suicide?

Yes   No 
If Yes, enter date

P

Has applicant been hospitalized for depression?

Yes   No 

P

Has applicant lost work due to depression?

Yes    No

P

Is applicant currently taking medication for depression?

P

Is applicant currently seeing a mental health therapist?

Yes   No 
If Yes, enter date of last visit

P

List any other illness or injury of applicant

P List all medications currently being used by applicant
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. 
 
£  Copyright 2008 - Consolidated Insured Benefits, Inc.     £  Web by CRMPublications         £   Terms of Use