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?