Seizure Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Have you been diagnosed or treated by a member of the medical profession for seizures or epilepsy?
Yes
No
When were you diagnosed by a member of the medical profession with your first seizure? How often per year do seizures occur? What was the date of your last seizure? What type of seizures do you have you been diagnosed with by a Grand Mal Petite Mal member of the medical profession? Has a member of the medical profession diagnosed a cause of your seizure disorder? (If yes, provide details.)
Other:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Please list all physicians that have treated you for your seizure disorder: (provide names and addresses):
Questions
Have you ever been hospitalized or seen in the Emergency Room due to your seizure disorder? (If yes, provide dates, names and addresses for all treatment persons or locations.)
Have you received treatment or been taking medication for your seizure disorder? (If yes, provide details including date last took medication.)
Any loss of work or disability associated with seizure disorder? (If yes, provide details.) Are you able to drive? (If no, since when and why not?)
Please provide any additional information you feel is important concerning your seizure disorder:
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-SQ.2
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