ALCOHOLISM


Please complete the following information:
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    Broker Information:
    Broker Name: *

    Phone: *

    Fax: *

    Email: *

    Address: *

    City: *

    State: *

    Zip: *

    Client Information:
    Insured's Name:

    Date of Birth:

    Sex:
    Male Female
    Type of Policy:
    State(s):
    Nicotine User: YES NO
    If YES: Cigarette Cigar Other:

    If NO: Number of years without:

  • Abstained from alcohol? YES NO
  • Date of last drink?
  • Reason for stopping?
  • Number of relapses, if any?
  • Current lifestyle?
  • Is client a member of AA or any organized rehabilitation group?
  • Has client undergone any other type of therapy or ever been hospitalized?
  • Any traffic violations or legal problems due to alcohol use? YES NO
  • Any residual damage (i.e., memory loss or liver damage)?
  • Is client taking antabuse? YES NO
  • Ever treated for a drug problem? YES NO
  • Additional Comments: