Alcohol Usage Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Do you presently use alcoholic beverages? (If yes, please record quantity in each category below. Number of glasses, ounces or bottles and whether on a daily, weekly or monthly basis.) Amount
Daily
Weekly
Monthly
Date of last drink
Beer
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Wine Liquor Did you ever drink substantially more than as outlined above? (If yes, please explain.)
Questions
Have you ever consulted a licensed medical professional and been diagnosed or received treatment because of your alcohol use, or been advised by a doctor to change or limit your alcohol consumption? (If yes, provide dates, names, and addresses of any doctors, hospitals or treatment centers.) Date
Doctors, Hospitals or Treatment Centers and Addresses
Have you ever been charged with impaired driving, lost your job or been arrested due to the influence of alcohol? (If yes, give details.)
Has any member of your immediate family been treated for or died due to excessive alcohol? (If yes, give details.)
I declare that all statements and answers to the foregoing questions are, to the best of my knowledge and belief, complete and true. I agree (a) that they shall form a part of my application; (b) that they shall be subject to the terms of the agreement found in the application; and, (c) that they shall become part of any policy based on my application.
Acknowledgement
Fraud Warning. Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Signature of Proposed Insured or Guardian
Date
GBU FINANCIAL LIFE
FL20-ALC.2
WWW.GBU.ORG | NEWBUSINESS@GBU.ORG PO BOX 645949, PITTSBURGH, PA 15264-5257 412-884-5100 | 800-765-4428
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