Impaired Risk Questionnaire For Alcohol

 

Alcoholism                 

Alcoholism involves impaired risk underwriting, where a person whose physical condition is less than standard or
who has a hazardous occupation or hobby, to help obtain the best tentative offers by several top rated
life insurance companies.

Please submit a completed form below to shop for the best possible premium:

* required information      **Please use TAB key to proceed to the next question field, not the ENTER key.**

Agent's Name*:
Address*:
Phone Number*:
E-Mail Address*:
Applicant's   Date Of Birth:
Sex: Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Has your client ever used tobacco or nicotine products? Yes No

If yes, what type of product did you use?
(Select all that apply)
Cigarettes Cigar Pipe Other

2. Has your client ever been treated for alcohol abuse?		 Yes No
When?
Where treated?
Date of last use:

3. Is your client a member of AA, NA, CA?		 Yes No
When did he/she join?
How often attended?

4. Has your client taken ANTABUSE?		 Yes No
Is he/she taking it now? Yes No
5. Has your client ever been convicted of any driving offenses related to alcohol? Yes No

If yes, give details:
6. Does your client have any medical problems, including liver disease or elevated enzymes related to your alcohol use?

Yes No
If yes, give details:
7. Before treatment how long had your client used alcohol?
How frequently?
8. Was there also drug abuse? Yes No
If Yes - What type of drugs?  
9. Before treatment how long had your client used drugs?
10. Does your client use any drugs now? Yes No
If Yes - What type of drugs?  
11. Additional Comments?