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Term Life Insurance for Individuals with Health Impairments

ASK THE DOCTOR
QUICK QUOTE FOR
DRUG USAGE

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's Name:

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
Tobacco Use:	Yes No
Replacement?	Yes No
Current Annum Premium	$
Last Life Ins. Application	Year Company Action
Occupation:
Marital Status:	Single Married Widow Divorced
Family History: (age if still living)	Father Mother Sibling 1 Sibling 2 Sibling 3
If any deceased, give relation(s), age(s), and cause(s):
Driving Record:	Number of violations in past 3 years? # of DUI / Reckless Driving in past 5 years?
Do you exercise 3 or more times per week? If yes, please give details:	Yes No
Date of last medical checkup:	00/00/0000
Date of last EKG:	00/00/0000 Results:
1. Please note client's condition:	Alcohol Abuse (Answer Q's 2-7) Drug Abuse (Answer Q's 8-10)
2. Does client currently consume any type of alcoholic beverage?	Yes No If yes, how often and in what amounts?
3. Is the client currently a member of AA or a simular support group?	Yes No
4. Has the client ever been hospitalized, institutionalized, or been an outpatient in an alcohol rehabilitation program? If yes, date of discharge?	Yes No 00/00/0000 (date of discharge)
5. In the last 10 years, list the date(s) of driving under the influence (DUI) arrests and convictions or check none.	None 00/0000 month/year 00/0000 month/year 00/0000 month/year
6. Results of the most recent liver function tests:
7. Is the client presently taking, or taken in the past, antabuse or another medication to help control drinking?	Yes No
8. Is the client using, or used in the past, any of the following substances or drugs (check box and detail).	Opiates/Narcartics: Heroin, Codeine, Morphine, Methodone, Demorol Barbiturates: Amytal, Phenobarbital Non-barbiturates: Placidly, doriden, Quaalude Amphetamines: Benzedreine, Dexedrine Methamphetamine: Cocaine, Crack, Ice Hallucinogens: LSD, Peyote, Psilocybin, Ecstasy Marijuana Other Detail Date, Last used Amount, Frequency:
9. Has the client ever been treated for substance abuse?	Yes No Detail Date(s), Place(s):
10. Has the client ever been arrested for possession, use, distribution of, or sale of an illegal substance?	Yes No Detail Date(s), Place(s):
11. List any ofther illnesses or impairments (complete any other quick quote forms that may apply), alone with all meds and vitamins taken, include dosage and frequency:
Please fill out all information completely and accurately.

E-DIRECT INSURANCE.
11/ 01/ 2005
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