Attention Deficit/Hyperactivity Disorder Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Do you, or have you ever, been diagnosed with Attention Deficit/Hyperactivity Disorder (ADD/ADHD)?
Yes
No
When was this diagnosed? Please list all physicians that have treated you for this condition: (Provide names, type of doctor and addresses.)
Date you last consulted above physician?
How often do you see?
Have you ever been hospitalized or seen in the Emergency Room due to your condition? (If yes, provide dates, names, and addresses for all treatment locations.)
Questions
Yes
No
Yes
No
Yes
No
Yes
No
Have you ever received treatment or medications for the condition? (If yes, provide details, including medications being taken, how often, and when last used.)
Is medication taken all year long or on a modified schedule? Are symptoms:
Improved
Same
More Severe
Are you receiving psychotherapy, counseling, or behavior modification? (If yes, provide details.)
Do you have any depression or other mood disorder problems associated with ADD/ADHD? (If yes, provide details.) Please provide any additional information you feel is important concerning your ADD/ADHD.
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 presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under the state law.
Signature of Proposed Insured or Guardian
Date
GBU FINANCIAL LIFE
ICC20-ADD/ADHD
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
1