Tobacco Summary Proposed Insured's Name: First Last DOB: Date Format: MM slash DD slash YYYY Sex: M F Height:Weight:Face Amount:Agent Information:Agent's Name:Phone:Email Address: Please answer the following about your Proposed Insured:Will the HOS test positive for nicotine? Yes No Which of the following tobacco products do you or have you used? Cigarettes Cigars Pipe Chewing tobacco Marijuana* Other How often do you use the products per year? Less than 12 times per year Less than 24 times per year If you selected Other, please explain:If you are no longer a user of tobacco products, when and why did you quit?When:Why:Are you on any medication(s)?Are you on any medication(s)? No Yes If yes, please provide details:Additional Underwriting Information:Underwriter's Notes:
