Impaired Risk Driving Violations Questionnaire
Agent Information
Agent Name		(required)
Address
Phone		(required)
Fax
E-Mail		(required)
LMG Marketing Rep:
Client Information
Client's name
Date of birth		mm    dd   yy
Sex		M    F
Height		Feet 2 ' 3 ' 4 ' 5 ' 6 ' 7 ' 8 ' 9 '   Inches 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"
Weight (lbs.)
Smoker		Yes    No
		(if yes, also complete tobacco questionnaire)
Insurance amount
Insurance type		Select one Term UL Survivor UL
Additional insured's name (only if applying for Survivor UL)
Other company(s) actions
Date applied		mm   yy
Company
Declined
Postponed
Rated table
1. When was the last speeding violation?
mm   yy
2. How many speeding violations have occurred in the past 5 years?
Number of violations
mm   yy		mm   yy
mm   yy		mm   yy
mm   yy		mm   yy
3. Does client currently hold a valid driver's license?
Yes    No
if yes, expiration date
state
4. When was the last accident involving major property damage?
mm   yy
5. Has client ever been convicted of driving under the influence of alcohol?
Yes    No
If yes, list all		mm   yy
		mm   yy
		mm   yy
6. Is the client currently being treated (or have ever been) for alcohol or drug abuse?
Yes   No
if yes, month/year/facility
7. Marital Status
Married Single Divorced
8. Occupation
Additional Information