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Quote Request for Diabetics
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 for X number of years
Include Waiver of Premium Y/N
Yes
No
Any other riders?
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 prescription medications for any reason? 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 we should know to identify our industry’s best fit life insurance solution:
Comments
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