Moral Hazards Questionnaire

DATE

ADVISOR NAME

PHONE ex. 555-555-1212

FAX ex. 555-555-1212

PROPOSED INSURED

DATE OF BIRTH

Male Female

STATE OF SALE

OTHER COMPANY ACTIONS:

Rated

Postponed Declined

OTHER COMPANY DETAILS:

TYPE OF PROBLEM (e.g. CRIMINAL RECORD, LACK OF APPLICANT CANDOR, CRIMINAL ASSOCIATES, CONVICTIONS, ETC.):

DATE(S) ASSOCIATED WITH INCIDENCE:

DATE OF LAST OCCURENCE:

WAS PROPOSED INSURED EVER CONVICTED?

Yes No

IF YES, HAS TIME BEEN SERVED OR IS CASE IN APPEAL? PLEASE EXPLAIN:

IS PROPOSED INSURED CURRENTLY ON PROBATION?

Yes No

IF YES, WHEN WILL PROBATION BE LIFTED?

PLEASE DESCRIBE ANY “LIFESTYLE” CHANGES (e.g. STABLE EMPLOYMENT, ETC.):

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