Drug Abuse Questionnaire Form Page 2
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27. Have you ever been a member or Alcoholics Anonymous, Narcotics
Yes ____
No___
Anonymous or a similar association?
If “Yes”, please provide details on the following:
a) When?
_________________________________________________________________________________________
b) How often do you attend meetings?
_________________________________________________________________________________________
c) Are you presently active?
Yes ____
No___
_________________________________________________________________________________________
d) Have you had any lapses?
Yes ____
No___
If “Yes”, please state relevant dates.
_________________________________________________________________________________________
8. Have you ever been arrested or convicted for any alcohol or drug related
Yes ____
No___
offence or been required to attend alcohol or drug awareness program ordered by the court?
If “Yes”, please provide details including dates for each occurrence.
_________________________________________________________________________________________
9. Have you ever taken time off work because of your drug use?
Yes ____
No___
_________________________________________________________________________________________
10. Have your working duties ever been affected or restricted in any way?
Yes ____
No___
If “Yes”, please provide details including dates and durations.
_________________________________________________________________________________________
11. Please provide full name and address of any association (e.g. Alcoholics Anonymous, Narcotics Anonymous,
etc) or doctor whom you have consulted due to drug abuse.
_________________________________________________________________________________________
I declare that to the best of my knowledge and belief, the information given by me is true and complete and that
no material facts (i.e. facts likely to influence the assessment and acceptance of my proposal for the life insurance)
have been withheld.
I agree that this form shall constitute a part of my proposal for Life Insurance with HSBC Insurance (Singapore)
Pte. Limited.
__________________________________
__________________________________
Signature of life insured/participant
Signature of policyowner/certificate holder
(if other than life insured/participant)
Date: _____________________________
Date: _____________________________
Page 2 of 2
HSBC Insurance (Singapore) Pte. Limited
10 Eunos Road 8, #11-01 Singapore Post Centre (South Lobby), Singapore 408600
Tel: (65) 6225 6111 Fax: (65) 6221 2188
Web site:
Company registration no. 195400150N
SGI NB SUQ_v1.0 May 2011
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