Alcohol use questionnaire - uw-alcq377

ALCOHOL USAGE
QUESTIONNAIRE
(to be completed by Proposed Life Insured) Name_____________________________________________________ Date of Birth _________________________ Policy # ________________________ 1. Do you presently use alcoholic beverages? When was the last occasion? ________________________________ Could the period of drinking extend over an evening, a day, a weekend or longer? Please give details. ____________________________________________________________________________________________________________ 2. Did you ever drink substantially more than at present? Dates: From ______________________________________________________ To ________________________________________________________ Why did you change your drinking habits?__________________________________________________________________________________________ When did you last drink to excess? _______________________________________________________________________________________________ 3. Have you ever consulted a doctor or received treatment because of alcohol abuse? If “Yes”, give names and addresses of doctors, hospitals or treatment centres consulted, with dates in each instance: ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ If “No”, have you ever considered doing so? 4. (a) Do you now use, or have you ever used antabuse? (b) Since you stopped drinking, have you had any relapse? (c) Have you ever been arrested for driving while under the influence of alcohol? If “Yes”, give details: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 5. Are you now, or have you ever been a member of Alcoholics Anonymous (AA), or a similar organization? If “Yes”, give details: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 6. Has any member of your immediate family been treated for or died due to excessive alcohol? If “Yes”, give details: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 7. Please provide any additional information which you feel is important to clarify the information requested herein.
___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 8. Other Comments: _____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ I understand that my answers to the above questions will be relied on by Transamerica Life Canada in establishing my premium rate. If the above answers are not true, complete and correctlyrecorded, any policy issued as a result of this questionnaire (being part of the Application for Life Insurance) may be rendered void on the grounds of misrepresentation or fraud.
I hereby declare that I have read all the questions and answers in this questionnaire and the statements and answers given above are true, complete and correctly recorded to the best of myknowledge and belief. I understand and agree that this questionnaire shall form part of my Life Insurance Application to Transamerica Life Canada.
Dated at _____________________________________________ this _______________ day of _____________________________________ 20 ________ _____________________________________________________________ _____________________________________________________________

Source: http://www.transamerica.ca/en/Resources/Documents/UW-ALCQ377.pdf