Impaired Risk Questionnaire For Diabetes




Diabetes involves impaired risk underwriting, where a person whose physical condition is less than standard or
who has a hazardous occupation or hobby, to help obtain the best tentative offers by several top rated life insurance

Please submit a completed form below to shop for the best possible premium:

* required information       **Please use TAB key to proceed to the next question field, not the ENTER key.**     

Agent's Name*:
Phone Number*:
E-Mail Address*:
Applicant's   Date Of Birth:
Sex: Male Female
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable

Has your client ever used tobacco or nicotine products?
Yes No

If yes, what type of product did you use? (Select all that apply)
Cigarettes Cigar Pipe Other
2. Date diagnosed?
3. Type of medication and dosage:
4. Has your client ever been hospitalized for diabetes? Yes No
5. When did your client last see your doctor?
How often does your client  visit?
6. Does your client have glycohemoglobin AIC tests done? Yes No
Does your client test his/her own sugar? Yes No
Does your client know the most recent result? Yes No
Date of last blood glucose level:
Is your client and your client's doctor pleased with your client's control? Yes No
7. Has your client had any kidney problems? Yes No
Any protein in the urine? Yes No
8. Has your client had any problem with his/her eyes? Yes No
Any treatment? When?
9. Any high blood pressure? Yes No
10. Any "heart trouble"? Yes No
(If Yes, Please complete the Heart Questionnaire also.)
11. Any neurological symptoms, loss of feeling in your client's feet?
12. Additional Comments?