Sleep Apnea Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
When was sleep apnea diagnosed? How was it diagnosed? (For example: sleep clinic, etc.) What was the Apnea Index (AI) or Apnea-Hypopnea Index (AHI) score during the sleep study? (This information is required.) What is the treatment? (for example: N-CPAP, BiPAP, surgery, weight loss, medication, untreated, etc.)
Questions
Date treatment started. Do you comply with the treatment prescribed?
Yes
No
Yes
No
Yes
No
If using C-PAP, how many nights per week do you wear the device greater than four (4) hours? Is the treatment effective? Have there been consequences of the sleep apnea since you began treatment? (For example: do you have any excessive daytime sleepiness, any impaired neuropsychological functioning, hypertension caused by sleep apnea or any other consequences of sleep apnea since treatment.)
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-SA
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
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