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Diabetes Questioner
Please complete all required information for a speedy quote. Thank you
Agent  Information:

Agent Name  

Address

City  

State Zip  

Email Address  

Phone   Fax  

Life License  

State Exp. Date  

Broker / Dealer  

Your client:

Name

D.O.B. Gender

HT   WT   STATE

Amount Required $

Max. Annual Premium $

Type of Insurance Perm.   Term Year's  Level

Tobacco Use:
Pipe
Cigar Chewing Cigarettes


If Replacing current annual premium?

Last Life Insurance App. year:

Company:

Action:

Requested Illustration:

1. CLIENT'S AGE AT ONSET OF DIABETES

2. WHAT IS THE METHOD OF CONTROL?
DIET ONLY
DIET AND ORAL MEDICATION (S)
DIET AND INSULIN INJECTION

3. HOW MANY TIMES A DAY IS CLIENT'S INSULIN ADMINISTERED?
ONE OR TWO TIMES PER DAY
THREE OR MORE TIME PER DAY
INSULIN PUMP

4. HOW OFTEN ARE CLIENT'S BLOOD SUGAR LEVELS MONITORED?
ONE OR TWO TIMES PER DAY
THREE OR MORE TIME PER DAY

5. PLEASE INDICATE ANY OF THE FOLLOWING EXPERIENCED;
EKG ABNORMALITIES
INSULIN REACTIONS
DIABETIC COMA
EYE TROUBLE
HEART TROUBLE
PROTEIN IN URINE
SKIN ULCERATION
AMPUTATIONS
NEUROPATHY OR LOSS OF FEELING

6. PLEASE DETAIL ANY INDICATIONS FROM QUESTION NUMBER 5, SUCH AS: TYPE OF; DATE OF; FREQUENCY OF OCCURRENCE;

7. HAS THE CLIENT HAD A GLYCOHEMOGLOBIN (A1C) TEST DURING THE PAST SIX MONTHS?
IF YES, PLEASE DETAIL LEVEL:
BELOW 7.5
7.6 TO 10
10.1 TO 13
ABOVE 13

8. HOW LONG HAS THE GLYCOHEMOGLOBIN LEVEL REMAINED CONSTANT?
0 TO 6 MONTHS
6 TO 12 MONTHS
OVER A YEAR

9. DATE OF CLIENT'S LAST VISIT TO A PHYSICIAN:
0 TO 6 MONTHS AGO
6 TO 12 MONTHS AGO
OVER 1 YEAR AGO

10. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO

11. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC   DIASTOLIC

12. CLIENT'S OCCUPATION

13. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL

14. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL

15. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:

    

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