Alcohol Use

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Alcohol Use Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has 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

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Alcohol Use

Alcohol Use Questionnaire