DUI / DWI 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

DUI / DWI Questionnaire

Which motor vehicle related incidents has the proposed insured had in the past 10 years?(Required)

Moving violation

Reckless driving

DWI / DUI

License suspension or revocation

For each incident, provide date of arrest, date of conviction, date of license suspension or revocation, and date of license reinstatement

Details, including any dismissal or court ordered requirements

Date of last alcohol use

Any relapses from previous attempts to stop drinking?

Yes

Has the proposed insured ever been advised by a doctor to stop or decrease their alcohol use?

Yes

Has the proposed insured attended any alcohol treatment programs?

Yes

If yes, provide name and type (in-patient or out-patient)

Does the proposed insured attend AA?

Yes

Probation start and end dates

Has the proposed insured had a breathing device on their vehicle?

Yes

If yes, date of insertion and date of removal

Any history of drug convictions?

Yes

If yes, provide details

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.