Developmental Delay Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Has a member of the medical profession diagnosed you with a developmental delay or learning disorder? Is there a cause or diagnosis? (If yes, provide details.)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
What age was this diagnosis? Have you received treatment, been given medication, or had any kind of therapy by a member of the medical profession for your delay (including physical, occupational or speech)? ( If yes, provide details.)
What grade level have you completed? Are you able to perform all instrumental activities of daily living (IADLs)? (shopping, food prep, housekeeping, transportation, managing your own finances or medications) (If no, provide details.)
Are you able to read and write? (If no, provide details.)
Questions
Are you able to live on your own? (If no, provide details.)
Are you currently working? (If yes, provide details of type of work.)
Are you treated by a physician for your delay? (Provide name and address.)
Please provide any additional information you feel is important for us to consider:
GBU FINANCIAL LIFE
FL20-DD.2
WWW.GBU.ORG | NEWBUSINESS@GBU.ORG PO BOX 645949, PITTSBURGH, PA 15264-5257 412-884-5100 | 800-765-4428 | FAX: 412-884-9815
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Developmental Delay Questionnaire (continued)
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.
Acknowledgment
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
FL20-DD.2
Date
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