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Term Life Insurance for Individuals with Health Impairments

ASK THE DOCTOR
QUICK QUOTE FOR
ALCOHOL ABUSE

INFORMATION GATHERED WILL BE USED IN THE EVALUATION OF THE INSURABILITY OF THE APPLICANT. OFFERS ARE TENTATIVE AND ARE SUBJECT TO VERIFICATION OF THE SUBMITTED MEDICAL EVIDENCE AND OTHER CRITERIA USED IN THE UNDERWRITING OF LIFE INSURANCE.© COPYRIGHT E-DIRECT INSURANCE

* Required Information

Applicant Information
* Applicant's Name:
* Date Of Birth:	00/00/0000
* Gender:	Male Female
* Height:	ft/in
* Weight:	lbs
* Occupation:
* Death Benefit:
* Type of Product:	Term Universal Whole Life Second to Die Variable
Have you ever used tobacco or nicotine products?	Yes No If yes, what type of product did you use? (Select all that apply) Cigarettes Cigar Pipe Other
Have you ever been treated for alcohol abuse?	Yes No
When?
Where treated?
Date of last use:
Are you a member of AA, NA, CA?	Yes No
When did you join?
How often do you attend?
Have you taken ANTABUSE?	Yes No
Are you taking it now?	Yes No
Have you ever been convicted of any driving offenses related to alcohol?	Yes No If yes, give details:
Do you have any medical problems, including liver disease or elevated enzymes related to your alcohol use?	Yes No If yes, give details:
Before treatment how long had you used alcohol?
How frequently?
Was there also drug abuse?	Yes No If Yes - What type of drugs?
Before treatment how long had you used drugs?
Do you use any drugs now?	Yes No If Yes - What type of drugs?
Additional Comments?
Please fill out all information completely and accurately.

E-DIRECT INSURANCE.
11/ 01/ 2005
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