Note: It is very important that you do your very best to provide accurate information. The more accurate the information is, the more accurate our proposal will be. This form cannot be processed unless the fields marked with an * are filled in.

* Name of Proposed Insured	* Street Address	* City	* State of Residence
* Zip Code	* Daytime Phone	* Evening Phone	* E-mail Address
* Date of Birth	* Do you smoke? (Yes or No)	* What is your gender?	* Height/Weight

Amount of coverage desired:

Type of product that you are interested in:
Whole Life Universal Life Term - 5 Year Term - 10 Year Term - 15 Year Term - 20 Year Disability Long Term Care Annuities Other

Alcoholism Related Questions

Abstained from alcohol?
Date of last drink?
Reason for stopping?
Number of relapse, if any?

Current lifestyle?

Is proposed insured a member of AA or any organized rehabilitation group? If so, please provide details?

Has the proposed insured undergone any other type of therapy or ever been hospitalized? Please provide details.

Any traffic violations or legal problems due to alcohol use? If so, please provide details

Any residual damage (i.e. memory loss or liver damage)? If yes, what type and when diagnosed?

Are blood studies normal? If no, where can we obtain a copy of the results?

Is proposed insured taking antabuse? If yes, how long and provide details.

Ever treated for drug problems? If so, when and provide details.

Proposed insured's exercise habits?

Thank you.