Drug Use Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Are you currently using or have you ever used or abused illegal or controlled substances? Check all drugs used or write in name of drugs if not listed.
Questions
Opium Derivatives
Heroine
Morphine
Hydromorphone
Percodan
Dilaudid
Methadone
Marijuana
Bhang Grass
Grass
Charas Pot
Ganja Tea
Hashish
Cannabis
Cheese
Amphetamines
Benzedrine
Dexedrine
Dolophine
Cocaine
Crank
Barbituates
Amytale
Phenobarbital
Seconal
Pentobarbital
Hallucinogens
LSD
DMT
Mescaline
Psilocybin
Peyote
Acid
Codeine
Morphine
Paregoric
Hydrocodone
Percodan Naloxone
Vicodin
Cyclazocine
Oxycodone
Mushrooms
STP
Thai Stick
Morning Glory Seeds
TWA
PCP
Angel Dust
Bennies
Crystal
Crystal Meth
Dextoamphetamines
Desoxyn
Epinephrine
Dexies
Pep pills
Speed
Methadrine
Methylphenidate
Uppers
Downers
Preludin
Librium
Chloral Hydrate
Diazepam
Miltown
Equanil
Meprobamate
Valium
Alcohol
Other
How Much
How Often
Date of your First Use
Date of your Last Use
Have you ever consulted a physician, counselor or clergy because of drug and/or alcohol use? (If yes, indicate dates, name and addresses of all treatments.) Date
Doctors, Hospitals or Treatment Centers and Addresses
Have you ever been charged with a driving violation due to drug(s) or alcohol or failed or refused to take a breathalyzer test? Have you ever experienced job difficulties, missed work, had family problems or legal problems due to drug or alcohol use?
Yes
No
Yes
No
Yes
No
GBU FINANCIAL LIFE
ICC20-DU
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
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Drug Use Questionnaire
Questions (Continued)
Have you ever been in an altercation or arrested or charged with a drug or alcohol related offense?
Yes
No
Do you have any family members that have been treated for or have drug or alcohol use?
Yes
No
Have you ever had any medical problems which were caused by drug or alcohol use?
Yes
No
Yes
No
Have you ever attended AA, NA or other support group(s) for drug or alcohol use? (If yes, provide name of group(s), date first attended, date last attended and how often you attend.) What is your current height and weight
Height:
Weight:
What was your weight one (1) year ago? 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-DU
Date
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