Please note that there are two situations that would keep us from obtaining a diabetic life insurance quote for you. First, you must have been diagnosed as a diabetic at least six months ago. The companies want at least that much time to review how your treatment is progressing. Secondly, your diabetes must be controlled, whether by insulin, diet and exercise or some other means doesn't matter, but if your diabetes is NOT under control currently we will not be able to get a quote for you.
Finally, although we can usually get coverage quoted for juvenile diabetics it is more difficult to obtain quotes for the very young. For adults with juvenile onset quotes are almost always higher than for adult onset.
Are you male or female?
What, if any, is your tobacco use (check all that apply)?
No Tobacco Use
Cigarettes
Cigars
Pipe
Smokeless Tobacco
What type of life insurance do you wish quoted?
If requesting term insurance, what length of time do you wish quoted?
Amount of Insurance to Quote:
Date of Birth:
What is your occupation?
How long have you been in this occupation?
What is your height?
What is your weight?
What was your weight one year ago?
What was your weight two years ago?
Reason(s) for any weight change.
When were you first diagnosed with diabetes?
Are you currently under treatment or medical supervision?
Yes
No
Type, amount and frequency of insulin dosage(s).
Do you ever stop insulin or go off your diet?
Yes
No
If the answer was YES, please provide details.
What personal monitoring do you do?
If you do monitoring, provide details of frequency of testing and results.
If you know your most recent A1c reading, please let us know that and the date of the reading.
Please list all prescription drugs that you take--their names, dosage and reason taken.
Do you have or have you had (check all that apply):
Abscesses
Boils
Carbuncles
Eye Trouble
Infections
Numbness or Tingling of Extremities
Ulcers of the Legs
Urinary Problems
If any condition above was checked, please provide details.
Check all that apply about your family history:
Both Parents Are Living
Both Parents Are Deceased
Mother Living; Father Deceased
Father Living; Mother Deceased
Mother Had/Has Cancer
Mother Had/Has Diabetes
Mother Had/Has Heart Disease
Father Had/Has Cancer
Father Had/Has Diabetes
Father Had/Has Heart Disease
How old is your mother or what was her age when deceased?
How old is your father or what was his age when deceased?
If either parent deceased, please provide cause of death.
Please provide ages and health of any brothers or sisters,
including age at death and cause of death if
deceased.
Please provide details of the last time you lost time from work, including reason, date and time lost.
Please provide details of the last time you were hospitalized, including reason and dates.
Enter any additional information you feel we need to know that would help us underwrite your case:
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