Alcohol Usage Questionnaire Form
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2HSBC Insurance (Singapore) Pte. Limited.
(Reg. No. 195400150N)
21 Collyer Quay #02-01 Singapore 049320, Monday to Friday 9.30am to 5pm.
Customer Care Hotline: (65) 6225 6111 Fax: (65) 6221 2188
Mailing address: Robinson Road Post Office P.O. BOX 1538 Singapore 903038.
Alcohol Usage Questionnaire
WARNING:
Statement Pursuant to Section 25(5) of the Insurance Act, you are to disclose in this form, fully and faithfully, all
the facts which you know or ought to know, otherwise the request effected hereunder may be void.
Proposal no
:_____________________________________
Name of life insured/participant
:_____________________________________
Name of policyowner/certificate holder
:_____________________________________
(if other than life insured/participant)
1. At what age did you first start to consume alcohol?
_________________________________________________________________________________________
2. Please state the type of alcohol (beer, wine, hard liquor, etc) and current amount consumed per week for
each type of alcohol.
_________________________________________________________________________________________
3. Have you ever consumed more alcohol than you do currently?
Yes ____
No____
If “Yes”, when and why did you change your drinking habits?
_________________________________________________________________________________________
4. Please state any further relevant particulars, which may have bearing on any past or present increase in
alcohol consumption. (e.g. Domestic or business upset. Please indicate N/A if not applicable)
_________________________________________________________________________________________
5. Have you ever been advised to reduce or discontinue your alcohol intake?
Yes ____
No____
If “Yes”, please provide details.
_________________________________________________________________________________________
6. Have you ever been referred for counselling or treatment, hospitalised or
Yes ____
No____
attended a clinic or Alcoholics Anonymous due to your alcohol consumption?
If “Yes”, please provide details.
_________________________________________________________________________________________
7. Have there been any tests or investigations carried out?
Yes ____
No____
(eg. Ultrasound, blood test, urine test, etc)
If “Yes”, please state the date, results and submit copies of the investigations report, if any.
_________________________________________________________________________________________
8. Have you ever received medical treatment for excessive consumption of
Yes ____
No____
alcohol? (e.g. Antabuse etc)
If “Yes”, please provide name of medication, dosage, frequency and date last taken.
_________________________________________________________________________________________
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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
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