Criminal History 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, pip, snuff, etc.)? Yes No Frequency: Date of last use: MM slash DD slash YYYY Type: Current Alcohol Use - Type: Current Alcohol Use - Amount per week: PLEASE NOTE: if the case involves multiple charges, provide answers/details for each charge.Date(s) of incident(s)/crime(s): Brief description of the circumstances surrounding the charge: List all charge(s) against the client: Misdemeanor or felony: Class (A or 1, B or 2, C or 3, D or 4): Date of conviction(s): Outcome of conviction(s): Did the client serve jail time - if yes, length of sentence: Release date from jail: Any parole or probation? Date parole or probation was completed: Have all court proceedings associated with the matter been discharged? Is the client employed? Yes No If employed, provide occupation and length of employment to date: Any history of drug/alcohol abuse - if yes, provide details: Any Motor Vehicle violations on record? If yes, provide details: 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 © 2017 Tellus Brokerage Connections Δ