Diabetic Questionnaire

Complete what you know and submit. Anything you leave blank will not stop the submission, but the more detail you give an underwriter, the faster we can shop the case.

Download the printable PDF

Agent & Case Information

Agent Name(Required)

First Last

Phone(Required)

E-Mail(Required)

Proposed Insured

Client Name(Required)

First Last

You may enter client initials. We don't share client information with carriers on risk assessments.

Date of Birth(Required)

State(Required)

Height(Required)

Weight(Required)

Face Amount(Required)

Sex(Required)

Male

Female

Tobacco / Nicotine Use(Required)

Yes

Coverage Requested

Type of Insurance

Universal Life

Whole Life

Survivorship

Term

If term, number of years

Diabetic Questionnaire

When was the proposed insured first diagnosed with diabetes?(Required)

What was the diagnosis?

Type I

Type II

Does the proposed insured receive any of the following treatments?

Diet control

Oral medication

Insulin

If oral medication, name, dosage and frequency

If insulin, units per day

How often is blood sugar checked?

Most recent blood sugar reading

Most recent A1C reading

How often does the proposed insured see their doctor for diabetes follow-up?

Has the proposed insured ever been in a diabetic coma?

Yes

If yes, provide date and circumstances

Is there any history of diabetes or heart disease in the proposed insured's family?

Yes

If yes, provide relationship to proposed insured and age of onset

Has the proposed insured experienced any of the following?

Eye trouble

Heart disease or chest pain

Poor circulation or leg cramps

Kidney disease

Neuropathy

Details for each of the above

Is the proposed insured currently taking any medication(s)?

Yes

If yes, provide name, dosage and frequency of medication(s)

Attachments

File Upload

Drop files here or

Max. file size: 512 MB.

Attach medical records, lab slips, pathology or test reports.

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Questions before you submit? Call the underwriting desk at 866.639.0443.