Complete each of the questions provided below.  Those questions with a P are required entries in order to process your application.  When all of the questions are complete select SUBMIT to complete the process.  We will contact you as soon as possible.

Applicant Contact Information

P

Applicant's Name

P State of Residence
P Applicants Date of Birth
P Sex   Male    Female
P Height
P Weight
P Smoker?   Yes    No
P Other Insurance Company Actions   Rated Table    Postponed    Declined
If Rated Table, Enter information here:

Applicant Health Background - Alcohol Usage Questionnaire

P

Does the applicant currently consume alcohol beverages?

Yes   No 
If Yes, enter quantity
 

 

Beer

Wine

Liquor
Daily
Weekly
Monthly


If No, date of last drink 

P

Did the applicant ever drink substantially more than at present?

Yes   No 
If Yes, enter quantity
 

 

Beer

Wine

Liquor
Daily
Weekly
Monthly


Dates from     to 

P

Why did applicant change their drinking habits?

P

Is applicant active in AA or other recovery groups
 

Yes    No
 If Yes, enter how long in treatment

P

Has the applicant ever consulted a doctor or received treatment because of alcohol use?

 

Yes    No

If Yes, enter name and address of doctor, hospital and/or treatment center below.

P

Has the applicant ever been arrested for a driving under the influence of alcohol?

Yes    No

If Yes, provide details below including license number

 

Other Information

Agent Information
P Agent Name
P Agency Name
P Address
P City
P State
P Phone
P Email
P Fax number
  Other Comments