Alcohol and drug qq

Alcohol & Drug Questionnaire

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 ___________
1. PLEASE NOTE CLIENT’S CONDITION:
8. IS THE CLIENT USING, OR USED IN THE PAST, ANY OF THE  ALCOHOL ABUSE (ANSWER QUESTIONS 2 – 7 AND 11) FOLLOWING SUBSTANCES OR DRUGS (CHECK BOX AND  DRUG ABUSE (ANSWER QUESTIONS 8 – 11) 2. DOES THE CLIENT CURRENTLY CONSUME ANY TYPE OF  OPIATES/NARCOTICS: HEROIN, CODEINE, MORPHINE,  NO  YES, HOW OFTEN AND IN WHAT AMOUNTS:  NON-BARBITURATES: PLACIDYL, DORIDEN, QUAALUDE ______________________________________________________  METHAMPHETAMINES: COCAINE, CRACK, ICE 3. IS THE CLIENT CURRENTLY A MEMBER OF AA, OR A SIMILAR  HALLUCINOGENS: LSD, PEYOTE, PSILOCYBIN, ECSTASY  OTHER _____________________________________________ 4. HAS THE CLIENT EVER BEEN HOSPITALIZED, INSTITUTIONALIZED, OR BEEN AN OUTPATIENT IN AN DETAIL DATES LAST USED, AMOUNT, FREQUENCY: ______________________________________________________  NO  YES, DATE OF DISCHARGE ______________________ 9. HAS THE CLIENT EVER BEEN TREATED FOR SUBSTANCE 5. WITHIN THE LAST 10 YEARS, LIST THE DATE(S) OF DRIVING UNDER THE INFLUENCE (DUI) ARRESTS AND CONVICTIONS, OR  NO  YES, DETAIL DATE(S) AND PLACE(S): _____________ MONTH _________________________ YEAR ________________ ______________________________________________________ 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): _____________ 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 DOSAGE AND FREQUENCY: _________________________________________ 7. IS THE CLIENT PRESENTLY TAKING, OR TAKEN IN THE PAST, ______________________________________________________ ANTABUSE OR ANOTHER MEDICATION TO HELP CONTROL DRINKING?  NO  YES 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 2007 CPS Insurance Services

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