Driving History Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Driver’s License Number:
State Issued:
Within the past three (3) years, have you had any of the following moving violations? Infraction
Date(s) of Infraction(s)
Number of Infractions
Speeding Infractions Improper turns Traffic signal offenses
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Failing to yield Driving on suspended license Other Within the past five (5) years, have you been convicted of any of the following? Infraction(s)
Questions
Date(s) of Infraction(s)
Number of Infractions
Careless or reckless driving Driving under the Influence (DUI); Driving While Intoxicated (DWI) (If any DUI/DWI history, please complete Alcohol Questionnaire.) Have you ever had any accidents? (If yes, provide details, including fault.)
Is your license currently suspended? (If yes, provide reason and anticipated reinstatement.)
Have you been licensed in any other states within the past five (5) years? (If so, please provide details.)
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-DH
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
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