Asthma Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
When were you diagnosed by a member of the medical profession with asthma? Number of attacks in the last year. Date of last attack? Please list the names of all medications taken, including the dosage and frequency of use.
Have you ever been hospitalized for asthma? (If yes, please provide the name of hospital and dates.)
Yes
Questions
No
Name and address of physician that is treating you.
Any other information that you can provide to help in determining your health in regards to your asthma?
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-ASTH.2
WWW.GBU.ORG | NEWBUSINESS@GBU.ORG PO BOX 645949, PITTSBURGH, PA 15264-5257 412-884-5100 | 800-765-4428
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