Qalcoholdrug

QUICK QUOTE FOR ALCOHOL AND DRUG USAGE
Information gathered will be used in the evaluation of the applicant’s insurability. Offers are tentative subject to verification of the submitted medical evidence and other criteria used in the underwriting of life insurance. COPYRIGHT CPS
CLIENT: NAME ____________________________________ / ❑ M ❑ F / DOB __________ AGE ______ / HT ______ WT _____ / STATE ______
AMT. REQUESTED $ _______________ / MAX. ANNUAL PREMIUM $ ___________________ / TYPE OF INS. ❑ UL ❑ TERM YRS. LVL _______
TOBACCO USE ❑ NO ❑ YES, TYPE ______________________ / REPLACEMENT ❑ YES ❑ NO / CURRENT ANN. PREM. $ _____________
LAST LIFE INSURANCE APP. YEAR _______ COMPANY ____________________________ ACTION ___________________________________
OCCUPATION __________________________________________ / MARITAL STATUS ❑ SINGLE ❑ MARRIED ❑ WIDOWED ❑ DIVORCED
DRIVING RECORD - # OF VIOLATIONS IN PAST 3 YEARS ________________ / # OF DUI / RECKLESS DRIVING PAST 5 YEARS ____________
DATE OF LAST MEDICAL CHECKUP ____________ / DATE OF LAST EKG _____________ AND RESULTS ______________________________
AGENT: NAME __________________________________________________ PHONE _______________________ FAX ____________________
ADDRESS ______________________________________________________ CITY _________________________ ST ______ ZIP ___________
CPS OFFICE ONLY: ENTER OFFICE NAME/LOCATION _______________________________________________ FAX _____________________
8. IS THE CLIENT USING, OR USED IN THE PAST, ANY OF THE FOLLOWING SUBSTANCES OR DRUGS (CHECK BOX AND ❑ ALCOHOL ABUSE (ANSWER QUESTIONS 2 – 7 AND 11) ❑ DRUG ABUSE (ANSWER QUESTIONS 8 – 11) ❑ OPIATES/NARCOTICS: HEROIN, CODEINE, MORPHINE, 2. DOES THE CLIENT CURRENTLY CONSUME ANY TYPE OF ❑ NON-BARBITURATES: PLACIDYL, DORIDEN, QUAALUDE ❑ NO ❑ YES, HOW OFTEN AND IN WHAT AMOUNTS: ❑ METHAMPHETAMINES: COCAINE, CRACK, ICE ______________________________________________________ ❑ HALLUCINOGENS: LSD, PEYOTE, PSILOCYBIN, ECSTASY 3. IS THE CLIENT CURRENTLY A MEMBER OF AA, OR A SIMILAR ❑ OTHER _____________________________________________ DETAIL DATES LAST USED, AMOUNT, FREQUENCY: 4. HAS THE CLIENT EVER BEEN HOSPITALIZED, INSTITUTIONALIZED, OR BEEN AN OUTPATIENT IN AN ALCOHOL ______________________________________________________ 9. HAS THE CLIENT EVER BEEN TREATED FOR SUBSTANCE ❑ NO ❑ YES, DATE OF DISCHARGE ______________________ 5. WITHIN THE LAST 10 YEARS, LIST THE DATE(S) OF DRIVING ❑ NO ❑ YES, DETAIL DATE(S) AND PLACE(S): ______________ UNDER THE INFLUENCE (DUI) ARRESTS AND CONVICTIONS, OR ______________________________________________________ MONTH _________________________ YEAR ________________ 10. HAS THE CLIENT EVER BEEN ARRESTED FOR POSSESSION, USE, DISTRIBUTION OF, OR SALE OF AN ILLEGAL SUBSTANCE? MONTH _________________________ YEAR ________________ ❑ NO ❑ YES, DETAIL DATE(S) AND PLACE(S): ______________ MONTH _________________________ YEAR ________________ ______________________________________________________ 6. PLEASE NOTE RESULTS OF MOST RECENT LIVER FUNCTION 11. LIST ANY OTHER ILLNESSES OR IMPAIREMENTS (COMPLETE ANY OTHER QUICK QUOTE FORMS THAT MAY APPLY) ALONG WITH ALL MEDS AND VITAMINS TAKEN (INCLUDE ______________________________________________________ 7. IS THE CLIENT PRESENTLY TAKING, OR TAKEN IN THE PAST, ______________________________________________________ ANTABUSE OR ANOTHER MEDICATION TO HELP CONTROL

Source: http://cpssac.com/docs/qalcoholdrug.pdf