Alcohol Consumption Questionnaire for Proposed Insured/Owner

Policy Number
Please fill in block letters & tick appropriate boxes and circles.
A. Personal Information of Proposed Insured / Applicant
Last Name First Name Ext Name Middle Name

m m d d y y y y
Date of Birth: / / Occupation:

Please indicate specific duties

B. Alcohol Consumption Questionnaire

1. Do you currently drink alcohol? Yes No If Yes, provide details below.
What are the type, amount and frequency of your alcohol usage
Type : __________________________________________________________________________________________
Amount : __________________________________________________________________________________________
Frequency : ___________________________________________________________________________________________

2. Have you ever been hospitalized for alcohol consumption? Yes No If Yes, provide details below.

m m d d y y y y m m d d y y y y
Date of Admission: / / Date of Discharge: / /
Name of Medical Institution:
Address : Contact number:
Attending Physician/s :

3. Have you ever been adviced to stopped drinking alcohol? Yes No If Yes, provide details below.
When : __________________________________________________________________________________
Why : __________________________________________________________________________________
Duration and Treatment : __________________________________________________________________________________

4. What are your medications?

Medication:
Name of Drug Dosage Date Started
(include Preparation) m m d d y y y y
/ /
/ /

/ /

5. Further Laboratory Tests

If yes, please provide further details:
Type of Laboratory/result: _________________________________________________________________________________
Type of Laboratory/result: _________________________________________________________________________________

6 Have you ever been arrested or suspended for driving under the influence of liquor
Yes No if Yes, provide details: ___________________________________________________________
C. Affirmation Section
I he re by de cl a re tha t the a ns we rs /s ta te me nts tha t I ha ve ma de to thi s que s ti onna i re a re true a nd a ccura te re pre s e nta ti ons of my he a l th
condi ti on. Shoul d FWD Li fe I ns ura nce Corpora ti on ne e d a ddi ti ona l i nforma ti on, I gi ve s a i d compa ny the a uthori ty to s e cure re cords a nd
the a bove me nti one d phys i ci a ns or me di ca l i ns ti tuti on to provi de the corpora ti on, to di s cl os e to FWD or i ts a uthori ze d Me di ca l
Re pre s e nta ti ve ,the Me di ca l I nforma ti on Bure a u or a ny gove rnme nt a ge ncy re qui ri ng s uch i nforma ti on or docume nts pe rta i ni ng to my
he a l th condi ti on. Furthe r, I a m ful l y a wa re tha t s ta te me nts ma de to thi s que s ti onna i re s ha l l form pa rt of a nd be the ba s i s for the i s s ua nce
of the pol i cy be a ri ng the s a me numbe r a s s ta te d a bove
m m d d y y y
Place Signed Date: / /

Name and Signature over Printed Name of Proposed Insured / Applicant Agent/Witness

Agent code