Criminal History Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Have you been arrested?
Yes
No
Yes
No
Yes
No
State and county of arrest? Provide dates and circumstances of arrest.
Are you awaiting trial? If no, were you convicted? Yes: Misdemeanor/Felony What was your sentence?
Questions
No
Are you currently on: Parole Probation None Date completed sentence or date off probation/parole? Were drugs or alcohol contributors to your arrest? (If yes, please provide details on your use.)
Please provide any additional information you feel is important concerning your criminal history:
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-CH
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
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