Motor Vehicle/DUI 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 Is the client currently employed? Yes No If yes, occupation: Any DUI/DWI violations? Yes No If yes, provide date(s): If yes, penalty imposed (e.g. jail, probation, fines, mandated classes, license suspension, etc.): If jail, length of jail time and release date: Is the client currently on probation? Yes No If yes, when will probation end? Is the client’s driver’s license currently valid? Has the client ever had a history of alcohol abuse or ever been advised by a physician or other person to cut back or abstain from drinking? Yes No If yes, provide full details below (e.g. how often and how much he or she was drinking, any inpatient or outpatient treatment with dates, attending AA, etc.). Does the client currently use alcohol? Yes No If yes, how much per sitting and how often? Any history of recreational drug use? Yes No If yes, provide details (e.g. type of drug(s) used, date of last use, etc.) In the last 5 years has the client had any speeding ticket(s)? Yes No If yes, provide date(s) and indicate how many MPH over the limit for each incident: If applicable, list any other motor vehicle violations with dates in the last 5 years. Has the client’s driver’s license ever been suspended? Yes No If yes, provide reason(s), date of suspension, and date of restoration: 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