Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Do you suffer from chronic pain?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
When did it first start? Where is the pain, and what is the cause? Is pain considered?
Mild
Is pain localized in one area or diffuse all over? Are you disabled? (If yes, for how long?)
Moderate
Severe
Localized
Diffuse
Please list all physicians that treat you for your pain condition (provide names and addresses):
Have you ever received treatment or been prescribed medication of any kind (including any walking aids)? (If yes, provide details.)
Questions Have you ever been referred for pain management? (If yes, provide details, names and addresses for all treatment locations.)
Are you currently being treated for depression? (If yes, provide details, names and addresses for all treatment locations.)
Please provide any additional information you feel is important concerning your chronic pain.
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 presents a false statement in an application for insurance may be guilty of a Acknowledgement criminal offense and subject to penalties under the state law. Signature of Proposed Insured or Guardian
ICC20-CP
GBU FINANCIAL LIFE www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Date
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