Alcohol and/or Drug Abuse Questionnaire

 

In order to obtain a quote, please fill out the following information and click "SUBMIT". We will receive your quote request by email and contact you if we need any additional information. Your quote will be forwarded to you in the way you designate ASAP.

Fields marked with an asterisk (*) are required
Agent/Broker Name: *
 
Company Name:
 
Street Address:
 
City:
 
State:
 
Zip Code:
 
Your Phone Number: *
 
E-mail Address: *
 
Your Fax Number:
State of Policy Issue: *
Applicant's Full Name:
D/O/B: * (mm / dd / yyyy)
/ /
Gender: *  
Height: * ft inches
Weight: * lbs.
What is the applicant's occupation?: *
Nicotine User?: *   Yes     No 
If yes, select what type of product used?

Product(s) to Quote: *

Life Insurance Disability Insurance Long Term Care
Death benefit requested (if applicable) $
Monthly Disability benefit requested (if applicable) $
Long Term Care 'Daily Benefit' requested (if applicable)
 $
Has the applicant ever been treated for alcohol or drug abuse? * Yes No
If yes, give details (when, for what substance, dates, etc.): (if applicable)
If yes, what treatment facility(s)?
Date of last alcohol use: * (mm / DD / yyyy)
/ /
Is the applicant a member of AA, NA, CA? *
 Yes No
If yes, when did they join?
(mm / DD / yyyy)
/ /
How often do they attend?
Has the applicant ever taken ANTABUSE? *
Yes No
Is Antabuse currently being taken? *
Yes No
Has the applicant ever been convicted of any driving offenses related to alcohol or drugs? * Yes No
Has the applicant ever been arrested for the use or possession of alcohol or a controlled substance (unrelated to operating a motor vehicle)? * Yes No
If arrested for driving related offense, or for use and/or possession of drugs or alcohol, give details:
Does the applicant have any medical problems, including liver disease or elevated enzymes related to controlled substance or alcohol abuse? * Yes No
If yes give details:
How long did the applicant use alcohol? *

Years
How frequently and what kind of alcohol (beer, wine, or liquor)? *

Frequency

Type
Is alcohol currently used (beer, wine, or liquor)? * Yes No
If yes - what kind of alcohol and how often?
Any additional comments, remarks, other health issues,etc.?
How would you like to receive the requested information? *
Postal Mail Email Fax Pickup

 

 

Close This Window

Copyright © <% =Year(Date()) %> Your Agency Name