Life Insurance Alcohol Questionnaire

Alcohol Questionnaire

The more detailed the information you can give me, the more accurate the quote I can give you.
What's your date of birth?*
Please give details of your current alcohol consumption*
Have you ever consumed more alcohol than you do currently? If yes, when and at what level of consumption?*
Have you every been advised by a health care professional or doctor to stop or reduce your alcohol intake or been advised to have treatment or to attend a support group or Specialist because of your alcohol use? If yes, please give details*
Have you ever been a member of Alcoholics Anonymous, Narcotics Anonymous or a similar support group for recovering addicts? If yes, please answer the following questions: When? How often do you attend meetings? How many meetings in the last 6 months? Are you presently active? When did complete abstinence start? Have you had any lapses (when?)*
Have you had any previous treatments with subsequent relapse?*
What date did you last consume alcohol?*
Please give details of any current medication prescribed?
What is your occupation?*
Please provide any additional information that you feel is important:
First Name*
Email*
Have you applied to any of these insurers?
- Aviva
- Irish Life
- Laya
- New Ireland
- Royal London
- VHI
- Zurich Life
- None of the above
Thanks for completing the form, now please hit the send button below so we can review and come back to you with an accurate quote.

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Life Insurance Alcohol Questionnaire

Alcohol Questionnaire

The more detailed the information you can give me, the more accurate the quote I can give you.

Thanks for completing the form, now please hit the send button below so we can review and come back to you with an accurate quote.

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