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Alcohol & Drug Usage Questioner
Please complete all required information for a speedy quote. Thank you
Agent  Information:

Agent Name  

Address

City  

State Zip  

Email Address  

Phone   Fax  

Life License  

State Exp. Date  

Broker / Dealer  

Your client:

Name

D.O.B. Gender

HT   WT   STATE

Amount Required $

Max. Annual Premium $

Type of Insurance Perm.   Term Year's  Level

Tobacco Use:
Pipe
Cigar Chewing Cigarettes


If Replacing current annual premium?

Last Life Insurance App. year:

Company:

Action:
Requested Illustration:

1. PLEASE NOTE THE CLIENT'S CONDITION:

ALCOHOL ABUSE
ANSWER QUESTION 2 THROUGH TO 7 AND 12 THROUGH TO 14.


DRUG OR OTHER SUBSTANCE ABUSE
ANSWER QUESTIONS 8 THROUGH 14

2. DOES THE CLIENT CURRENTLY CONSUME ANY TYPE OF ALCOHOLIC BEVERAGE?
IF YES, HOW OFTEN AND IN WHAT AMOUNT:



3. IS THE CLIENT CURRENTLY A MEMBER OF AA OR A SIMILAR SUPPORT GROUP?


4. HAS THE CLIENT EVER BEEN HOSPITALIZED, INSTITUTIONALIZED, OR BEEN AN OUTPATIENT IN AN ALCOHOL REHABILITATION PROGRAM?
IF YES, LIST TIME OF DISCHARGE: Month   Year

5. WITHIN THE LAST SIX YEARS, LIST THE OCCASION AND THE DATE OF DRIVING UNDER THE INFLUENCE (DUI) ARRESTS AND CONVICTIONS:
NONE
Month
  Year
Month
  Year
Month
  Year
Month
  Year

6. RESULTS OF THE CLIENT'S MOST RECENT LIVER FUNCTION TESTS:

7. IS THE CLIENT PRESENTLY TAKING, OR TAKEN IN THE PAST, ANTI ABUSE OR ANOTHER MEDICATION TO HELP CONTROL DRINKING?

8. IS THE CLIENT USING, OR USED IN THE PAST, ANY OF THE FOLLOWING SUBSTANCES OR DRUGS: (CHECK BOX AND DETAIL BELOW)
OPIATES/NARCOTICS: HEROIN, CODEINE, DEMEROL, MORPHINE, ETHADONE, 
BARBITURATES: AMYTAL, PHENOBARBITAL
NON-BARBITURATES: PLACIDLY, DORIDEN
QUAALUDE
AMPHETAMINES: BENZEDRINE, DEXEDRINE
METHAMPHETAMINE: COCAINE, CRACK, ICE
HALLUCINOGENS: LSD, PEYOTE, PSILOCYBIN
ECSTASY
MARIJUANA


OTHER SUBSTANCE

AMOUNT AND FREQUENCY

LAST USED: Month
  Year


9. HAS THE CLIENT EVER BEEN TREATED FOR SUBSTANCE ABUSE?
 
IF YES, Month
  Year  
PLACE


10. HAS THE CLIENT EVER BEEN ARRESTED FOR POSSESSION, USE, DISTRIBUTION OF, OR SALE OF AN ILLEGAL SUBSTANCE?
LAST USED: Month
  Year
CITY
STATE

11. CLIENT'S MARITAL STATUS:

12. CLIENT'S OCCUPATION

13. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:

    

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