Cpshorizon.com

QUICK QUOTE FOR ALCOHOL AND DRUG USAGE

CLIENT: NAME ____________________________________ /  M  F / DOB __________ AGE ______ / HT ______ WT _____ / STATE ______
AMT. REQUESTED $ _______________ / MAX. ANNUAL PREMIUM $ ___________________ / TYPE OF INS.  UL  TERM YRS. LVL _______
TOBACCO USE  NO  YES, TYPE ______________________ / REPLACEMENT  YES  NO / CURRENT ANN. PREM. $ _____________
LAST LIFE INSURANCE APP. YEAR _______ COMPANY ____________________________ ACTION ___________________________________
OCCUPATION __________________________________________ / MARITAL STATUS  SINGLE  MARRIED  WIDOWED  DIVORCED
FAMILY HISTORY –
AGE, IF STILL LIVING: FATHER _____________ MOTHER ______________ SIBLING 1 ___________ SIBLING 2 __________ SIBLING 3 ________
IF ANY DECEASED GIVE RELATION, AGE AND CAUSE, OF EACH ________________________________________________________________
HAVE ANY OF YOUR FAMILY MEMBERS BEEN DIAGNOSED WITH CANCER, DIABETES OR HEART DISEASE; SPECIFY MEMBER AND
ILLNESS PRIOR TO AGE 60. GIVE RELATION, AGE AND ILLNESS, OF EACH_______________________________________________________
DRIVING RECORD - # OF VIOLATIONS IN PAST 3 YEARS ________________ / # OF DUI / RECKLESS DRIVING PAST 5 YEARS ____________
DO YOU EXERCISE 3 OR MORE TIMES PER WEEK?  NO  YES, DETAILS _____________________________________________________
DATE OF LAST MEDICAL CHECKUP ____________ AND RESULTS _______________________________________________________________
DATE OF LAST EKG _____________ AND RESULTS ____________________________________________________________________________
LAST BLOOD PRESSURE READING (EXAMPLE 140/80) _____________/ ARE YOU TREATED FOR BLOOD PRESSURE  NO  YES
LAST TOTAL CHOLESTEROL READING AND HDL READING _____________, ______________ / TREATED FOR CHOLESTEROL  NO  YES
AGENT: NAME __________________________________________________ PHONE _______________________ FAX ______________________
ADDRESS ______________________________________________________ CITY _________________________ ST ______ ZIP ______________
CPS OFFICE ONLY: ENTER OFFICE NAME/LOCATION _______________________________________________ FAX _____________________
________________________________________________________________________________________________________________________
1. INDICATE ALL THAT APPLY:
8. IS THE CLIENT USING, OR USED IN THE PAST, ANY OF THE  HISTORY OF ALCOHOL ABUSE (ANSWER QUESTIONS 2 – 7 FOLLOWING SUBSTANCES OR DRUGS (CHECK BOX AND  HISTORY OF DRUG ABUSE (ANSWER QUESTIONS 8 – 11)  OPIATES/NARCOTICS: HEROIN, CODEINE, MORPHINE, ** 2. DOES THE CLIENT CURRENTLY CONSUME ANY TYPE OF  NO  YES, HOW OFTEN AND IN WHAT AMOUNTS:  NON-BARBITURATES: PLACIDYL, DORIDEN, QUAALUDE ______________________________________________________  METHAMPHETAMINES: COCAINE, CRACK, ICE 3. IS THE CLIENT CURRENTLY A MEMBER OF AA OR A SIMILAR  HALLUCINOGENS: LSD, PEYOTE, PSILOCYBIN, ECSTASY IF YES, HOW OFTEN DOES CLIENT ATTEND?_______________  OTHER _____________________________________________ 4. HAS THE CLIENT EVER BEEN HOSPITALIZED OR BEEN AN PROVIDE DATES LAST USED, AMOUNT AND FREQUENCY: OUTPATIENT IN AN ALCOHOL REHABILITATION PROGRAM? ______________________________________________________  NO  YES IF YES, DATE OF DISCHARGE _______________ 9. HAS THE CLIENT EVER BEEN TREATED FOR SUBSTANCE 5. WITHIN THE LAST 10 YEARS, LIST THE DATE(S) OF DRIVING UNDER THE INFLUENCE (DUI) ARRESTS AND CONVICTIONS, OR  NO  YES, DETAIL DATE(S) AND PLACE(S): ______________ ______________________________________________________ MONTH _________________________ YEAR ________________ 10. HAS THE CLIENT EVER BEEN ARRESTED FOR POSSESSION, MONTH _________________________ YEAR ________________ USE, DISTRIBUTION OF, OR SALE OF AN ILLEGAL SUBSTANCE? MONTH _________________________ YEAR ________________  NO  YES, DETAIL DATE(S) AND PLACE(S): ______________ ______________________________________________________ 6. PLEASE NOTE RESULTS OF MOST RECENT LIVER FUNCTION 11. IS THE CLIENT CURRENTLY ON PROBATION? DATE __________________DETAILS;________________________ 12. LIST ANY OTHER IMPAIRMENTS (COMPLETE ANY OTHER QUICK QUOTE FORMS THAT MAY APPLY) ALONG WITH ALL 7. IS THE CLIENT PRESENTLY TAKING, OR TAKEN IN THE PAST, ANTABUSE OR ANOTHER MEDICATION TO HELP CONTROL DRINKING?  NO  YES, DETAILS_______________________ ________________________________________________________ ** If abstinent, approximately how long?

Source: http://www.cpshorizon.com/afi/inhouse_underwriting_Life/docs/qalch.pdf