DRUGS

Please complete the following information:
* Indicates a required field
    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:

  • How long has the client abstained from drug use?
  • Did client participate in a rehabilitation program?
    YES NO
    If Yes, Inpatient or Outpatient?
    For how long?
  • What type of drugs used?
  • How often used?
  • Dosage or amount used?
  • Are there any other medical problems?
  • Ever been treated for alcohol?
    YES NO
    If yes, please fill out the Alcohol Questionnaire after you submit this form.
  • Ever been treated for an overdose?
    YES NO
  • Any relapses?
    YES NO
  • Additional Comments: