Diabetes Quote Requestt

Diabetes Impaired Quote Request Form

Client Information

Name

Address

City, State, Zip

Day Phone

Evening Phone

Cell Phone

Fax

Date of birth

mm dd yy *

Sex

M F *

Height

Weight (lbs.)

Smoker

Yes No *

(if yes, also complete tobacco questionnaire)

Insurance amount

Insurance type

Additional
insured's name
(only if applying
for Survivor UL)

Other company(s) actions

Date applied

mm yy

Company

Declined

Postponed

Rated table

1. What was your age when diagnosed with diabetes?

2. What method is used to control it?
	Diet only Diet and oral medication (list) Diet and insulin injections
3. How often is insulin administered?
	On an insulin pump 1 or 2 times per day 3 or more times per day
4. How often are sugar levels monitored?
	1 or 2 times per day 3 or more times per day
5. When was the last visit to a physician?
	0-6 months 6-12 months 12-24 months more than 24 months
6. Do you have any of the following?
	EKG abnormalities Insulin reactions Diabetic coma Any eye trouble Heart trouble Protein in urine Skin ulcerations Amputations Neuropathy or loss of feelings
	other
7. Have you had a glycohemoglobin (AIC) test in the past 6 months?
	Yes No
8. If yes to #7, what was the level?

9. Are you receiving treatment or under supervision now?
	Yes No
10. How long has the glycohemoglobin level remained constant?
	0-6 months 6-12 months more than 12 months
11. Date and result of last blood pressure reading, with or without medication.
	mm yy
12. Is cholesterol level below 200?
	Yes No
13. How many times per week do you exercise?

	Type of exercise
14. Has either parent, or any sibling, died before age 65, other than by accident?
	Yes No (If yes, list relationship(s) and cause)
	cause
	cause
	cause
Additional Information

* Required