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Marijuana

Marijuana 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
MM slash DD slash YYYY
Client Name
Date of Birth
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
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

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