Alcohol / Drug Use Questionnaire

Complete what you know and submit. Anything you leave blank will not stop the submission, but the more detail you give an underwriter, the faster we can shop the case.

Download the printable PDF

Agent & Case Information

Agent Name(Required)

First Last

Phone(Required)

E-Mail(Required)

Proposed Insured

Client Name(Required)

First Last

You may enter client initials. We don't share client information with carriers on risk assessments.

Date of Birth(Required)

State(Required)

Height(Required)

Weight(Required)

Face Amount(Required)

Sex(Required)

Male

Female

Tobacco / Nicotine Use(Required)

Yes

Coverage Requested

Type of Insurance

Universal Life

Whole Life

Survivorship

Term

If term, number of years

Alcohol / Drug Use Questionnaire

Does the proposed insured currently drink alcohol?(Required)

Yes

If no, date of the last drink

If yes, provide alcohol type, frequency and quantity

Beer (cans or bottles), wine (glasses), liquor (ounces), and whether daily or weekly.

Does the proposed insured currently use drugs?(Required)

Yes

If no, provide the date of last use, type of drugs used, frequency and quantity

If yes, provide the type, frequency and quantity

Marijuana, cocaine or other (specify), and whether daily or weekly.

Did the proposed insured ever use alcohol or drugs more than as stated above?

Yes

If yes, time period from and to

Type, quantity and frequency during that period

Reason for change

Is the proposed insured an active member of an alcohol or narcotics recovery program (AA / NA)?

Yes

If yes, for how long?

Has the proposed insured ever joined and then left an alcohol or narcotics recovery program?

Yes

If yes, why?

Has the proposed insured ever consulted a physician, received or been advised to receive treatment because of alcohol or drug use?

Yes

If yes, provide dates of treatment, type of treatment and description

Has the proposed insured ever taken prescribed medication to treat alcohol or drug abuse?

Yes

If yes, provide names of medications and dates used

Has the proposed insured ever been convicted of an alcohol or drug related offense?

Yes

If yes, provide the type of convictions and dates

Is the proposed insured currently taking any medication(s)?

Yes

If yes, provide name, dosage and frequency of medication(s)

Attachments

File Upload

Drop files here or

Max. file size: 512 MB.

Attach medical records, lab slips, pathology or test reports.

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Questions before you submit? Call the underwriting desk at 866.639.0443.