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Alcohol Use Underwriting Questionnaire

Agent's Name: *

First

Last

Agent's Phone Number: *

Agent's Email: *

State of Issue/Delivery: *

Send to Additional Email?

Proposed Insured's Name: *

First

Last

Sex: *

Male
Female

What is the proposed insured's: *

Date of Birth
Age

Please select "age" if the date of birth is unknown.

Date of Birth: *

Age: *

Height: *

Weight: *

Ever a marijuana/THC user? *

Current marijuana/THC user? *

How is/was the marijuana or THC consumed? *

Smoked
Drops
Pills
Vape
Other

Please describe: *

Quantity used per occasion: *

How often do/did you use marijuana or THC? *

Ever a cigarette smoker? *

Current cigarette smoker? *

Date last used:

Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) *

Please provide details for any other tobacco use:

Last date any form of tobacco was used:

Is this case being premium financed? *

Do you have a lender? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts?

Face Amount:

Are you requesting any riders?

Type of rider:

Waiver of premium
Child term rider
LTC/CI type rider
Other

Please specify:

Alcohol Use

Do you presently use alcohol? *

Date of last alcohol use:

Note: One drink = 12g of pure alcohol = 12 oz. of beer = 5 oz. of wine = 1.5 oz. hard liquor

Current Alcohol use (indicate quantity below)

Daily - Beer

Daily - Wine

Daily - Liquor

Daily - Dates: (From – to)

Weekly - Beer

Weekly - Wine

Weekly - Liquor

Weekly - Dates: (From – to)

Monthly - Beer

Monthly - Wine

Monthly - Liquor

Monthly - Dates: (From – to)

Did you ever drink substantially more than now?

Daily - Beer

Daily - Wine

Daily - Liquor

Daily - Dates (From – to)

Weekly - Beer

Weekly - Wine

Weekly - Liquor

Weekly - Dates (From – to)

Monthly - Beer

Monthly - Wine

Monthly - Liquor

Monthly - Dates (From – to)

Have you ever been diagnosed with alcoholism?

Date of diagnosis:

Were there any relapses from sobriety/abstinence?

Please list dates:

Have you ever had an elevated liver blood test?

Most recent results:

Have you gone through alcohol treatment?

Please select:

Voluntary
Court Ordered

Please provide details:

Do you attend AA or similar?

How often?

Have you ever been arrested for driving while intoxicated?

Please list dates:

Was your driver’s license ever revoked/suspended?

Please list dates:

Have you ever experienced any adverse medical conditions as a result of your alcohol use?

Please provide details:

Have you ever been hospitalized as a result of alcohol use?

Please provide details:

Please provide additional details about the proposed insured’s medical history and provide any information that would help us negotiate the lowest rates (change in lifestyle, marriage, children, etc.):

Does the proposed insured take any medications (prescription or otherwise) at this time?

Medication 1:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 2:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 3:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 4:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 5:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

More than five medications?

Name of Medication (Prescription or Otherwise), Date Started Using, Date Stopped Using, Quantity Taken, and Frequency Taken:

Please provide additional details about the proposed insured’s medical history:

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Diversified Brokerage Services, Inc.

5501 Excelsior Blvd
Minneapolis, MN 55416
Phone 800.869.1DBS / 952.697.5000
Fax 952.697.5001

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Securities offered through The Leaders Group, Inc. Member FINRA/SIPC. 26 W. Dry Creek Circle, Suite 800, Littleton, CO 80120, 303.797.9080. Diversified Brokerage Services is not affiliated with The Leaders Group, Inc.

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