Diabetic Questionnaire

 

In order to obtain a quote, please fill out the following information and click "SUBMIT". We will receive your quote request by email and contact you if we need any additional information. Your quote will be forwarded to you in the way you designate ASAP.

Fields marked with an asterisk (*) are required
Agent/Broker Name: *
 
Company Name:
 
Street Address:
 
City:
 
State:
 
Zip Code:
 
Your Phone Number: *
 
E-mail Address: *
 
Your Fax Number:
State of Policy Issue: *
Applicant's Full Name:
D/O/B: * (mm / dd / yyyy)
/ /
Gender: *  
Height: * ft inches
Weight: * lbs.
What is the applicants occupation?: *
Nicotine User ?: * Yes     No 
If yes, select what type of product used?

Product(s) to Quote: *

Life Insurance Disability Insurance Long Term Care

Death benefit requested: (if applicable) $
Monthly Disability benefit requested: (if applicable) $
Long Term Care 'Daily Benefit' requested: (if applicable)
 $
Date of onset: * (mm / dd / yyyy)
/ /
When did the applicant last consult a doctor or medical practitioner about the condition: *
 (mm / dd / yyyy)
/ /
Has the applicant been hospitalized for the condition: *
Yes No
If yes, give details:
Is applicant currently (or in the past) being treated or taking prescription medication for the condition: *
Yes No
If yes, describe medications being taken: (name of medication, dosage, frequency, etc.)
Does applicant have glycohemoglobin AIC tests done: * Yes No
Does applicant test their own blood glucose level: * Yes No
If yes, what was the date of the most recent reading and the result:

(mm / dd / yyyy)
/ /

Result
Is your blood glucose level stable and in control: * Yes No
Has applicant had complications with their eyes: * (Please give details including treatment in 'Remarks' section below) Yes No
Has applicant had complications with their kidneys: * (Please give details including treatment in 'Remarks' section below) Yes No
Has applicant had protein present in their urine: * (Please give details including treatment in 'Remarks' section below) Yes No
Has applicant had elevated blood pressure: * Yes No
If yes, what is the most recent reading: (please also complete High Blood pressure questionnaire) Result
Has applicant had heart trouble: * Yes No
If yes, give details including dates: (please also complete Heart questionnaire)
Has applicant had loss of feeling or complications in feet or body extremities: * Yes No
If yes, give details including dates:
Has applicant had neurological symptoms or trouble: * Yes No
If yes, give details including dates:
Does the condition effect or limit the applicant's employment: * Yes No
If yes, please give details:
Any additional comments, remarks, other health issues,etc.?
How would you like to receive the requested information? *
Postal Mail Email Fax Pickup

 

 

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