Tobacco and Nicotine Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Do you currently smoke cigarettes? If yes, how many packs per day and how many years have you smoked cigarettes?)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Did you ever smoke cigarettes? If yes, when did you stop (month/year), why did you stop, how many packs per day?)
If yes, have you smoked any cigarettes in the past twelve (12) months?
Questions
Do you currently use tobacco or nicotine products in any form, including smoking cessation (gum, patches, prescription medications)? (If yes, please describe.)
If yes, provide specific products used, frequency of use and date of last use.
Have you used tobacco or nicotine products in any form, including smoking cessation (gum, patches, prescription medications) in the past twelve (12) months? (If yes, please describe.)
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
Your signature indicates your authorization to investigate the accuracy of your statements.
GBU FINANCIAL LIFE
ICC20-NSQ
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
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