GDB Life Questions

Guaranteed Death Benefit health questionnaire. Complete all sections accurately to help us determine your coverage options.

Insured First Name *

Insured Date of Birth *

Insured Gender *

Male

Female

Beneficiary Information

Beneficiary First Name *

Beneficiary Last Name *

Street Address Line 2

Percentage Share? * If divided between addt'l beneficiaries, total must equal 100%.

Relationship with Insured *

Any Other Beneficiary? (List Information)

Will the Proposed Insured be the Owner? *

Yes

Is there a successor policy owner? *

Yes

Health & Policy Questions

Is there any life insurance policy or annuity contract in force or application pending on the life of the Proposed Insured, including policies sold or assigned to a trust or viatical/life settlement company? *

Yes

YES ONLY, please list: Insured Name, Company Name, and Policy Number.

Will any life insurance policy or annuity contract on the Proposed Insured be reduced, replaced, discontinued or payment of premium stopped, if the insurance applied for is issued? *

Yes

YES ONLY, please list: Insured Name, Company Name, and Policy Number.

Do you have a terminal illness? *

Yes

YES ONLY, please list: Type of terminal illness.

Are you bedridden, or receiving any professional nursing care or health care services in the home? *

Yes

YES ONLY, please list: Why are you bedridden, or receiving any professional nursing care or health care services in the home?

Are you currently hospitalized or confined to a nursing, assisted living, long term care or rehabilitation facility? *

Yes

YES ONLY, please list: Why are you currently hospitalized or confined to a nursing, assisted living, long term care or rehabilitation facility?

Have you been told by a member of the medical profession that you have a disease or disorder which will result in death within 24 months or less, or are you receiving oxygen therapy (not including treatment for Sleep Apnea)? *

Yes

YES ONLY, please list why:

Which coverage are you interested in? *

How Did You Hear About Us *

How can we help you?

GDB Life Questions

GDB Life Questions Form

Insured Information

Beneficiary Information

Policy Ownership

Health & Policy Questions