Underwriting Questionnaire
Marijuana Use
Producer Name Phone Date
Client Name Date of Birth
Male Female Face Amount Max Premium $ /yr.
Term Permanent Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snu, etc.)? Yes No
Frequency Date of last use Type
For Insurance Professional Use Only. Not intended for use in solicitation of sales to the public. Not intended to recommend the use of any
product or strategy for any particular client or class of clients. For use with non-registered products only. Crump operates under the license
of Crump Life Insurance Services, Inc., AR license #100103477. Products and programs oered through Crump are not approved for use in
all states. Updated April 14, 2020
Copyright © 2020 Crump Life Insurance Services, Inc.
Date client rst used marijuana How many times per week does the client use marijuana
How is it ingested (smoked, drops, pills, etc.)
Quantity used per occasion
Is the marijuana use medicinal Yes No
If yes, advise prescription date
If yes, what condition(s) is marijuana prescribed for
Other history of using drugs (past or present). Provide full details including type(s) of drug used, date(s) used and date(s) of last use
Does the client use alcohol Yes No Frequency How much per occasion
Has the client received treatment for drug or alcohol abuse Yes No If yes, provide details
Has the client ever had a DUI/DWI Yes No If yes, provide details, including date(s)
Does the client have any motor vehicle violations on his or her records Yes No If yes, provide details including type of
violation(s) and date(s)
Client’s occupation
If the client works in the marijuana industry, provide full disclosure of company name, position, and duties in the space below.
List any other major health problems the client has: