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Guaranteed Life Insurance

Straightforward | Efficiency Focused

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Life Insurance Carrier Quotes
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THE PURE COMPARISON
PRIVACY POLICY

Life Insurance Nerds

Guaranteed Life Insurance

Straightforward | Efficiency Focused

Life Insurance Carrier Quotes
LIFE EXPECTANCY CALCULATORS
INTERNAL RATE OF RETURN ON DEATH BENEFITS (IRR)
UNDERWRITING, IMPAIRED RISK & HEALTH ASSESSMENTS
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
PRIVACY POLICY

Life Insurance Nerds

Guaranteed Life Insurance

Straightforward

Efficiency Focused

ABOUT
Contact
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
INTERNAL RATE OF RETURN (IRR)
LIFE EXPECTANCY CALCULATORS
UNDERWRITING, IMPAIRED RISK & HEALTH
PRIVACY POLICY

Alcohol Usage Questionnaire

DATE

ADVISOR NAME

PHONE ex: 555-555-1212

FAX ex: 555-555-1212

Client Information

PROPOSED INSURED

DATE OF BIRTH

Male Female

STATE OF SALE

TABACO USE

Yes No Quit

QUIT WHEN?

OTHER COMPANY ACTIONS:

RATED

Rated

TABLE

POSTPONED/DECLINED

Postponed Declined

OTHER COMPANY DETAILS:

DO YOU PRESENTLY CONSUME ALCOHOL?

Yes No

DATE OF LAST DRINK

IF YES, QUANTITY:

DAILY

WEEKLY

MONTHLY

BEER

How Much Beer Daily?

How Much Beer Weekly?

How Much Beer Monthly?

WINE

How Much Wine Daily?

How Much Wine Weekly?

How Much Wine Monthly?

LIQUOR

How Much Liquor Daily?

How Much Liquor Weekly?

How Much Liquor Monthly?

DID YOU EVER DRINK SUBSTANTIALLY MORE THAN AT PRESENT?

Yes No

IF YES, DATES:

Date From

Date To

IF YES, QUANTITY:

DAILY

WEEKLY

MONTHLY

BEER

How Much Beer Daily?

How Much Beer Weekly?

How Much Beer Monthly?

WINE

How Much Wine Daily?

How Much Wine Weekly?

How Much Wine Monthly?

LIQUOR

How Much Liquor Daily?

How Much Liquor Weekly?

How Much Liquor Monthly?

ARE YOU ACTIVE IN A.A. OR OTHER RECOVERY GROUPS?

No Yes

HOW LONG?

HAVE YOU EVER CONSULTED A DOCTOR OR RECEIVED TREATMENT BECAUSE OF ALCOHOL USE?

Yes No

IF YES, PLEASE INDICATE THE NAME AND ADDRESS OF ANY DOCTOR, HOSPITAL OR TREATMENT CENTER:

HAVE YOU EVER BEEN ARRESTED FOR DRIVING UNDER THE INFLUENCE OF ALCOHOL?

Yes No

IF YES, DATES:

Date Arrested?

PLEASE LIST ANY MEDICATIONS CURRENTLY BEING TAKEN AND THEIR DOSAGE:

HAS EITHER PARENT OR ANY SIBLING DIED BEFORE AGE 65, OTHER THAN BY ACCIDENT?

Yes No

DETAILS

ARE YOU CURRENTLY EMPLOYED OR CAPABLE OF BEING EMPLOYED?

Yes No

ADDITIONAL COMMENTS:

The form was sent successfully.

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Life Insurance Nerds Corporate Division

2155 Butterfield, Suite 102 South

Troy, MI 48084

877-637-3717

info@lifeinsurancenerds.com

HOME
ABOUT
BLOG
Contact

HOME
ABOUT
BLOG
Contact

Calculators
Assessments
IRR

Calculators
Assessments
IRR

LIFE SETTLEMENT
The PURE Comparison
The PURE Solution

LIFE SETTLEMENT
The PURE Comparison
The PURE Solution