Developmental Delay Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Do you have a developmental delay or learning disorder? Is there a cause or diagnosis? (If yes, provide details.)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
What age was this diagnosis? Have you received treatment, been given medication, or had any kind of therapy for your delay (including physical, occupational or speech)? (If yes, provide details.)
What grade level have you completed? Are you able to perform all instrumental activities of daily living (IADLs)? (shopping, food prep, housekeeping, transportation, managing your own finances or medications) (If no, provide details.)
Are you able to read and write? (If no, provide details.)
Questions Are you able to live on your own? (If no, provide details.)
Are you currently working? (If yes, provide details of type of work.)
Are you treated by a physician for your delay? (Provide name and address.)
Please provide any additional information you feel is important for us to consider:
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-DD
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
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