Controlled Substance Use 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 applicants occupation?: *
Does the applicant use nicotine products?: * 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 applicant ever been treated for alcohol or illegal drug abuse? * Yes No
If yes, give details (what treatment facility, what substance, dates, etc.):
Date of last illegal drug use:
(mm / DD / yyyy)
/ /
Is applicant a member of AA, NA, CA? *
 Yes No
When did they join?
(mm / DD / yyyy)
/ /
How often do they attend?
Has the applicant ever been convicted of any driving offenses related to alcohol or illegal drugs? * Yes No
Has the applicant ever been arrested for the use or possession of illegal drugs or alcohol (unrelated to operating a motor vehicle)? * Yes No
If arrested for driving related offense, or for use and/or possession of illegal drugs or alcohol, give details:
Does the applicant have any medical problems, including liver disease or elevated enzymes related to illegal drug or alcohol abuse? * Yes No
If yes give details:
Are controlled substances currently being used? * Yes No
How frequently and what kind of substance(s) used?

Frequency

Substance Used
If yes - what kind of controlled substance is used 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

 

 

 

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