Ask the Doctor – Alcohol

Obtain a tentative offer for a case involving Alcohol Abuse by completing the form below:

* required information

**Please use TAB key to proceed to the next question field, not the ENTER key.**

1. *Agent Name :
*Address :
*City:
*State:
*Zip:
Agent E-Mail:
Agent Phone:
2. Applicant’s Name:
Date Of Birth:
Sex:	Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product:	Term Universal Whole Life
	Second to Die Variable
Have you ever used tobacco or nicotine products?	Yes No If yes, what type of product did you use? (Select all that apply) Cigarettes Cigar Pipe Other
3. Have you ever been treated for alcohol abuse?	Yes No
When?
Where treated?
Date of last use:
4. Are you a member of AA, NA, CA?	Yes No
When did you join?
How often do you attend?
5. Have you taken ANTABUSE?	Yes No
Are you taking it now?	Yes No
6. Have you ever been convicted of any driving offenses related to alcohol?	Yes No If yes, give details:
7. Do you have any medical problems, including liver disease or elevated enzymes related to your alcohol use?	Yes No If yes, give details:
8. Before treatment how long had you used alcohol?
How frequently?
9. Was there also drug abuse?	Yes No If Yes – What type of drugs?
10. Before treatment how long had you used drugs?
11. Do you use any drugs now?	Yes No If Yes – What type of drugs?
12. Additional Comments?