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Motor Vehicle/DUI Underwriting Questionnaire
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Agent's Name:
*
First
Last
Agent's Phone Number:
*
Agent's Email:
*
State of Issue/Delivery:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
*
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Age:
*
Height:
*
Weight:
*
Ever a marijuana/THC user?
*
Yes
No
Current marijuana/THC user?
*
Yes
No
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?
*
Yes
No
Current cigarette smoker?
*
Yes
No
Date last used:
MM
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1920
Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.)
*
Yes
No
Please provide details for any other tobacco use:
Last date any form of tobacco was used:
MM
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Is this case being premium financed?
*
Yes
No
Do you have a lender?
*
Yes
No
Insurance Type:
*
Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product
Face Amount:
*
Are there multiple policies/face amounts?
Yes
No
Face Amount:
Are you requesting any riders?
Yes
No
Type of rider:
Waiver of premium
Child term rider
LTC/CI type rider
Other
Please specify:
Motor Vehicle/DUI
Is the proposed insured employed?
Yes
No
Occupation:
Any DUI/DWI violations?
Yes
No
Provide date(s):
Penalty imposed? (e.g. jail, probation, mandated classes, license suspension, etc.)
Did the proposed insured spend time in jail?
Yes
No
Length of jail time:
Release date:
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1920
Is the proposed currently on probation?
Yes
No
When will probation end?
Any history of alcohol abuse or an advisement by a physician or other person to cut back or abstain from drinking?
Yes
No
Provide full details (e.g. how often and how much, any inpatient or outpatient treatment with dates, attending AA, etc.)
Does the proposed currently use alcohol?
Yes
No
How much per sitting?
How often?
Any history of recreational drug use?
Yes
No
What type(s)?
Date of last use:
MM
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YYYY
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1924
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1922
1921
1920
In the last 5 years has the proposed insured had any speeding tickets?
Yes
No
Provide date(s) and indicate how many MPH over the limit for each incident:
If applicable, list any other motor vehicle violations with dates in the last 5 years:
Is the proposed insured’s driver’s license currently valid?
Yes
No
Has the proposed insured’s driver’s license ever been suspended?
Yes
No
Please provide reason(s), date of suspension(s), and date(s) of restoration:
Is the proposed insured’s driver’s license currently suspended?
Yes
No
When will it be restored?
Please provide any applicable information about the proposed insured that may help us understand the full history:
Does the proposed insured take any medications (prescription or otherwise) at this time?
Yes
No
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?
Yes
No
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:
Submit
