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Quote Request for Diabetics
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Advisor Name
Advisor Email Address
Advisor Phone Number:
Applicant Name (Optional)
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Death Benefit amount(s) to quote:
Coverage is needed for how many years? Forever?
Include Waiver of Premium Y/N
Yes
No
At what age was the applicant diagnosed with diabetes?
Which form of diabetes was diagnosed?
Type 1
Type 2
Most recent A1c reading:
Range of A1c readings during past 12 months:
What medications are used to control the diabetes?
If insulin is used, which types and quantity:
Height and weight:
Change in weight the past 12 months?
Please list any diabetic complications such as retinopathy, nephropathy:
Describe any regular exercise and how often this activity is completed:
Any tobacco use in past 3 years (cigarettes, cigars, chewing, dipping, vaping, pipe) - describe use and frequency:
Any marijuana use in past 12 months (any time, smoked, vaped, gummies) - describe use and frequency:
Does the applicant take any other prescription medications? If so, please list each, and what condition(s) each is prescribed for:
List other medical conditions, moving violations, hazardous activities, sports, military service, foreign travel, family history, or private aviation:
Provide any other information that might be relevant to underwriting. Thank you!
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