STAR UNION DAI-ICHI LIFE INSURANCE CO. LTD.

ALCOHOL QUESTIONNAIRE
Name: Policy No:

1. a) How many alcoholic drinks do you usually have in a week? 1peg=30ml ○ 0-12 pegs ○ 13-24 pegs
○ 25-50 pegs ○ More than 50
pegs

○
b) How long have you been drinking to this extent? ○ Less than 6 ○ 6-24 months
months ○ More than 5
○ 2-5 years years

c) How often do you drink alcoholic beverages? ○ Daily or almost ○ Other

daily _______________
○ Mostly on
weekends

2. Have you ever been advised to reduce your alcohol consumption? ○ No

○ Yes

If “Yes”, name and address of doctor who has complete records:

__________________________________________________________

__________________________________________________________

3. Indicate average number of drinks per week when advised to reduce consumption?

○ 0-12 drinks ○ 13-24 drinks ○ 25-50 drinks ○ More than 50 drinks

4. Have you received medical treatment for drinking/alcoholism or attended a Rehabilitation centre? ○ No

○ Yes

If “Yes”:

a) Name and address of institution:

__________________________________________________________

__________________________________________________________ b) Date of treatment: __________________________

○ No
5. a) Are you a member of Alcoholics Anonymous (AA)? ○ Yes

b) Do you attend meetings regularly? ○ No

○ Yes

6. Has your licence ever been suspended or revoked for an alcohol-related offence? No  Yes 

Date(s)
Suspended Offence

DECLARATION BY THE LIFE TO BE ASSURED

I understand and agree that the statements in the proposal form and all supplementary questionnaires will be the basis of the contract between me and
Reliance Life (the Company) and that if any statement is untrue or inaccurate, or if any matter material to this proposal is not disclosed, the company may
void the contract and all premiums paid will be forfeited to the Company. I agree that I will inform the Company if between the date of this proposal and the
date of issue of this policy there is any change in my health so that the Company may reconsider its terms of acceptance. I understand that if I fail to do so,
then the Company may void the policy and all premiums paid will be forfeited to the Company. I further agree that the foregoing questions and answers
shall form part of the proposal for insurance made by me to the Company.

_____________________________________________________ _____________________________________________________
Date Signature of Life Insured
Alcohol Questionnaire Version 1.0.1