Marijuana 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 Date client first used marijuana: How many times per week does the client use marijuana? How is it ingested (smoked, drops, pills, etc.)? Quantity used per occasion: Is the marijuana use medicinal? Yes No If yes, advise prescription date: If yes, what condition(s) is marijuana prescribed for? Other history of using drugs (past or present). Provide full details including type(s) of drug used, date(s) used and date(s) of last use: Does the client use alcohol? Yes No Frequency: How much per occasion: Has the client received treatment for drug or alcohol abuse? Yes No If yes, provide details: Has the client ever had a DUI/DWI? Yes No If yes, provide details, including date(s): Does the client have any motor vehicle violations on his or her records? Yes No If yes, provide details, including type of violation(s): Client's occupation: If the client works in the marijuana industry, provide full disclosure of company name, position, and duties in the space below. 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 © 2017 Tellus Brokerage Connections Δ