Alcoholism Impaired Risk Underwriting

Alcoholism                   Alcoholism involves impaired risk underwriting.  Obtain a tentative life insurance offer by completing the form below: * required information **Please use TAB key to proceed to the next question field, not the ENTER key.** Applicant's Name*: Applicant's Address*: Applicant's Phone Number*: Applicant's E-Mail Address*: 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 2. Have you ever been treated for alcohol abuse? Yes No When? Where treated? Date of last use: 3. Are you a member of AA, NA, CA? Yes No When did you join? How often do you attend? 4. Have you taken ANTABUSE? Yes No Are you taking it now? Yes No 5. Have you ever been convicted of any driving offenses related to alcohol? Yes No If yes, give details: 6. Do you have any medical problems, including liver disease or elevated enzymes related to your alcohol use? Yes No If yes, give details: 7. Before treatment how long had you used alcohol? How frequently? 8. Was there also drug abuse? Yes No If Yes - What type of drugs? 9. Before treatment how long had you used drugs? 10. Do you use any drugs now? Yes No If Yes - What type of drugs? 11. Additional Comments?

Declined from other Life Insurance Companies Do you Have A Medical Condition For An Impaired Risk or Participate In A Hazardous Hobby? Click on the topic below to complete an impairment questionnaire. We will respond within 72 hours. Alcohol Anxiety Blood Pressure Cancer History Cholesterol Crohn's Disease Depression Diabetes Hepatitis C Melanoma Pilot Heart Race Car Driver Scuba Diving Smoker Valve Replacement Have questions... Send an e-mail to the "Doc" Related:

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TermLifeAmerica.com- Lewis Fink is licensed as an insurance agent offering Life Insurance in the following states: Alabama - AL, Arkansas - AR, California - CA, Colorado - CO, Connecticut - CT, Delaware - DE, District of Columbia - DC, Florida - FL, Georgia - GA, Idaho - ID, Illinois - IL, Indiana - IN, Iowa - IA, Kansas - KS, Kentucky - KY, Louisiana - LA, Maine - ME, Maryland - MD, Massachusetts - MA, Michigan - MI, Mississippi - MS, Missouri - MO, Montana - MT, Nebraska - NE, New Mexico - NM, New Jersey - NJ, New York - NY, North Carolina - NC, North Dakota - ND, Ohio - OH, Oklahoma - OK, Pennsylvania - PA, Rhode Island - RI, South Carolina - SC, South Dakota - SD, Tennessee - TN, Texas - TX, Utah - UT, Vermont - VT, Virginia - VA, and Wisconsin - WI.  


Not all insurance products from all insurance companies are available in all states.


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