Travel And Residence Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Past travel history outside the United States: Please list each city and country to which you have traveled in the past two (2) years, the length of stay in each location and the specific date of travel. City and Country
Length of Stay
Date(s)
Future travel history outside the United States: Please list each city and country to which you will be traveling within the next two (2) years and the length of stay in each location. City and Country
Length of Stay
Date(s)
Questions
Describe the purpose of your past and future travel. If your travel is business-related, please describe your duties.
What is your birthplace? Are you a US citizen? (If no, indicate country of citizenship, type of visa and attach photocopy of visa/passport.) Country of permanent residence.
Yes
No
How long?
How long have you resided in the United States?
Acknowledgment
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. 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-FTR.2
WWW.GBU.ORG | NEWBUSINESS@GBU.ORG PO BOX 645949, PITTSBURGH, PA 15264-5257 412-884-5100 | 800-765-4428
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