Impaired Risk
Driving Violations Questionnaire
Agent Information
Agent Name
(required)
Address
Phone
(required)
Fax
E-Mail
(required)
LMG Marketing Rep:
Client Information
Client's name
Date of birth
mm
dd
yy
Sex
M
F
Height
Feet
2 '
3 '
4 '
5 '
6 '
7 '
8 '
9 '
Inches
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight (lbs.)
Smoker
Yes
No
(if yes, also complete tobacco questionnaire)
Insurance amount
Insurance type
Select one
Term
UL
Survivor UL
Additional insured's name (only if applying for Survivor UL)
Other company(s) actions
Date applied
mm
yy
Company
Declined
Postponed
Rated table
1. When was the last speeding violation?
mm
yy
2. How many speeding violations have occurred in the past 5 years?
Number of violations
mm
yy
mm
yy
mm
yy
mm
yy
mm
yy
mm
yy
3. Does client currently hold a valid driver's license?
Yes
No
if yes, expiration date
state
4. When was the last accident involving major property damage?
mm
yy
5. Has client ever been convicted of driving under the influence of alcohol?
Yes
No
If yes, list all
mm
yy
mm
yy
mm
yy
6. Is the client currently being treated (or have ever been) for alcohol or drug abuse?
Yes
No
if yes, month/year/facility
7. Marital Status
Married
Single
Divorced
8. Occupation
Additional Information