Alcohol Usage Questionnaire Form Page 2
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29. Have you ever consulted a doctor or received medical advice or treatment
Yes ____
No____
within past years with reference to liver disease, heart disease or blackouts?
If “Yes”, please provide details.
_________________________________________________________________________________________
10. Are you currently or previously on follow up?
Yes ____
No____
If “Yes”, please state date of last consultation and/or next appointment.
_________________________________________________________________________________________
11. Have you ever been involved in any breach of law, including traffic
Yes ____
No____
offences, in connection with the use of alcohol?
If “Yes”, please provide details.
_________________________________________________________________________________________
12. How long have you been in your present employment? Please provide brief description of the nature of
your
job.
If present employment is less than five years, please give details of previous occupations.
_________________________________________________________________________________________
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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