Alcohol Use QuestionnairePlease answer all questions applicable to the client's medical history. Questions? Call Jim or Teresa at 877.564.1707. Producer Name* Phone* Email* Date MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)? Yes No Frequency Date of Last Use Type Does the client use alcohol? Yes No If no, date of last alcohol use: Quantity Beer Wine Liquor How often? In the past, did the client drink substantially more than now? If yes, provide details below. Yes No Quantity Beer Wine Liquor How often? Has the client ever been treated for excessive alcohol use? Yes No If yes, provide details below, including dates:Has the client ever been arrested for driving under the influence (DUI) or for driving while intoxicated (DWI)? Yes No If yes, provide details below, including dates:Does the client attend AA or similar? Yes No If yes, how often? Is the client taking or has the client ever been prescribed Antabuse or any other medication to control his/her drinking? If yes, provide name of medication and details:List any other major health problems the client has: For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2016 Tellus Brokerage Connections Δ