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Updated: 05/07/2004

 

Drug Usage
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 - Drug Usage

P

Is the applicant using or have used any of the following drugs.

 

If any of these were prescribed by a doctor check the last column
                                    Yes No 

Prescribed by Doctor
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:  LDS,DMT, Mescaline, Peyote, Psilocybin, PCP
Sedatives and Tranquilizers:  Librium, Valium, Quaalude, Dalmane, Placidyl

 

P

If any of the above drugs were prescribed by a doctor provide details including the drug, quantity and frequency of use.

P

Except for drugs prescribed by a physician, is the applicant now using other drugs not listed in the first question above.

Yes   No 

 

If Yes, Explain Here

P

Has applicant ever sought medical treatment because of drug use?

Yes    No  
 If Yes, include dates, name of doctors and institutions below
  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

Consolidated Insured Benefits Quotation Policy  After filling out the necessary information on this form you will receive a quote via phone or email and then have the option of applying for the actual overage. There is no commitment for filling out the information on this form and receiving a quote. 
 
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