Abstained from alcohol?
Date of last drink?
Reason for stopping?
Number of relapse, if any?
Current lifestyle?
Is proposed insured a member of AA or any organized rehabilitation group? If so,
please provide details?
Has the proposed insured undergone any other type of therapy or ever been hospitalized?
Please provide details.
Any traffic violations or legal problems due to alcohol use? If so, please provide
details
Any residual damage (i.e. memory loss or liver damage)? If yes, what type and when diagnosed?
Are blood studies normal? If no, where can we obtain a copy of the results?
Is proposed insured taking antabuse? If yes, how long and provide details.
Ever treated for drug problems? If so, when and provide details.
Proposed insured's exercise habits?
Family History
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