Hypertension Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last)
Questions
When were you first diagnosed with hypertension?
Date of Birth
Is your hypertension under control?
Yes
No
Do you have any history of heart of circulatory problems?
Yes
No
Have you ever been hospitalized for high blood pressure or circulatory problems?
Yes
No
Date when physician indicated hypertension was under control. What prescription medication(s) is/are taken, and what are the dosages and frequency for each?
How long have you been on the medication(s) above?
Please list your last three (3) to four (4) blood pressure readings and the dates.
What is your current height and weight?
Height:
Weight:
What was your weight one (1) year ago? Please list the doctor’s name, address and phone number that treats you for high blood pressure.
Please list the dates of the last three (3) times you had an office visit/consultation with the physician listed above.
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-HYPTN
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
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