Moseleymcgill – Criminal History

Criminal History 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, pip, snuff, etc.)?
- Yes
- No
Frequency:
Date of last use:
Date Format: 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:
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Criminal History

Criminal History Questionnaire