Drug Impairment Quote

Drug Use Quote Request Form

Alcohol usage questionnaire Click Here

Client Information

Name

Address

City, State, Zip

Day

Evening

Cell

Fax

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. Are you now using, or has ever used in the past, any of the following drugs?
		Opium derivatives Heroin, Morphine, Demerol, Methadone, Codeine or Percodan, Dilaudid
		Barbiturates Amytal, Phenobarbital, Seconal, Nembutal, Pentobarbital
		Marijuana Hashish, Cannabis
		Amphetamines Benzedrine, Dexedrine, Methedrine, Preludin
		Cocaine
		Hallucinogens LSD, DMT, Mescaline, Peyote, Psilocybin, PCP
		Sedatives/Tranquilizers Librium, Valium, Quaalude, Dalmane, Placidyl
2. Were any of the above prescribed by a physician?
	Yes No
	if yes, which?
3. If "yes" to answers in 1 and 2, please give details
	type
	usual quantity
	frequency of use
	List dates:
	from:		mm yy
	to:		mm yy
4. Except those prescribed by a physician, are you now using or ever used in the past, any other drugs not listed in numbers 1 or 2 above?
	Yes No
	if yes,explain
5. Have you ever sought medical treatment because of drug use?
	Yes No
	if yes, state dates and names of doctors and institutions consulted
Additional Information

* Required