Impaired Risk Drug / Alcohol 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. Is client now using, or has ever used in the past, any of the following drugs?
	Opium derivatives Heroin, Morphine, Demerol, Methadone, Codeine or Percodan, Dilaudid
	Barbiturates Amytal, Phenobarbital, Seconal, Nembutal, Pentobarbital
	Marijuana Hashish, Cannabis
	Amphetamines Benzedrine, Dexedrine, Methedrine, Preludin
	Cocaine
	Hallucinogens LSD, DMT, Mescaline, Peyote, Psilocybin, PCP
	Sedatives/Tranquilizers Librium, Valium, Quaalude, Dalmane, Placidyl
2. Were any of the above prescribed by a physician?
Yes    No
if yes, which?
3. If "yes" to answers in 1 and 2, please give details
type
usual quantity
frequency of use
List dates:
from:		mm   yy
to:		mm   yy
4. Except those prescribed by a physician, is client now using or ever used in the past, any other drugs not listed in numbers 1 or 2 above?
Yes    No
if yes,explain
5. Has client ever sought medical treatment because of drug use?
Yes    No
if yes, state dates and names of doctors and institutions consulted
Additional Information