Alcohol Quote Request



Alcohol Quote Questionnaire Request Form Drug usage questionnaire Click Here
About You
	Name		*
	Address
	City, State, Zip		*
	Day Phone		*
Evening Phone
Cell Phone
Email		*

Your Information

	Date of birth		mm dd yy *
	Sex		M F *
	Height		*
	Weight (lbs.)		*
	Smoker		Yes No *

	Insurance amount		*
	Insurance type
	Additional insured's name (only if applying for Survivor UL)

Other company(s) actions
	Date applied		mm yy
	Company
	Declined
	Postponed
	Rated table

1. Do you presently consume alcoholic beverages?
	Yes No
	If no, date of last drink		mm yy
	If yes, quantity
	Beer		quantity
	Wine		quantity
	Liquor		quantity
2. Do you ever drink substantially more than at present?
	Yes No
	If yes, list dates:
	from:		mm yy
	to:		mm yy
	Why did you change drinking habits?
	Quantity
	Beer		quantity
	Wine		quantity
	Liquor		quantity
3. Are you active in A.A. or other recovery groups?
	Yes No
	if yes, how long
4. Have you ever consulted a doctor or received treatment because of alcohol use?
	Yes No
	if yes, indicate name and address of any doctor, hospital or treatment center
5. Have you ever been arrested for driving under the influence of alcohol?
	Yes No
	if yes, give details and driver's license number
Additional Information

	* Required