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Motor Vehicle/DUI

Motor Vehicle/DUI 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
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

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