Alcohol and Drug Abuse


If your client has a history of Alcohol or Drug Abuse, please answer the following:



Agent Name:  

Client Name: 

Phone:  

Fax: 
   

1.  Have you ever been treated for alcohol or sustance abuse ?  Yes   No 
Where and when ?  Length of treatment  
Date of last use:  

2.  Are you a member of AA, NA, CA ?  Yes   No  
When did you join ?  How often do you attend ?  


3.  Have you ever taken ANTABUSE ?  Yes   No 
Are you taking it now ? Yes No 4. Have ever been convicted of any driving related or criminal offenses relating to alcohol or substance abuse ? Yes No If yes, give details: 5. Do you have any medical problem, including liver disease or elevated enzymes related to your alcohol use ? Yes No If yes, give details: 6. Prior to treatment how long had you used alcohol ? How frequently ? 7. Have you ever been treated for drug abuse ? Yes No If Yes - What type of drugs? 8. Before treatment how long had you used drugs? 9. Do you use any drugs now? Yes No If Yes - What type of drugs?


The underwriter will respond back to you on this case within 48 hours.