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: 01/15/2006

Diabetes 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 (First, Last)

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
P Age at onset of diabetes?
P Current method of control   Diet only
  Diet and insulin injections  (Frequency)
       Use insulin pump   1-2 times/day  3 or more times/day
  Diet and oral medications  (List medications below)
P How often do you monitor sugar levels?   1-2 times/day    3 or more times/day
P Please indicate which of following the applicant has experienced.   EKG abnormalities   Insulin reactions
    Diabetic coma   any eye trouble
  Heart trouble   Protein in urine
  Skin ulcerations    Amputations
  Neuropathy or loss of feeling      Other
P Has applicant had a glycohemoglobin (A|C) test?   Yes    No
If Yes check level  below 7.5  7.6 - 10  10.1 - 13  above 13
P Is applicant receiving treatment or under supervision now?   Yes    No
P How long has the glycohemoglobin level remained constant   0 to 6 months  6 to 12 months  13 months or more
P What has been most recent blood pressure readings with or without medications - to the best of your knowledge B.P.  /

Medications in use, if any:

P Last time visited physician   0 to 6 months  6 to 12 months  12 to 24 months > 24 months
P Is cholesterol level below 200?   Yes    No
P Does applicant exercise 3 or more times/week on regular basis?   Yes    No
P Has either parent or any brother/sister died before age 65, other than by accident?   Yes    No
If Yes, explain: 
P Other notes regarding this case
 

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