No Exam Diabetes Questionnaire

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No Exam Diabetes Questionnaire

1
State of Residence* This field is required.
Alabama
Alaska
Arizona
Arkansa
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2
Gender* This field is required.
Female
Male
3
Date of Birth* This field is required.
4
Coverage Amount* This field is required.
$350,000
Less Than $25,000
$25,000
$50,000
$75,000
$100,000
$125,000
$150,000
$175,000
$200,000
$225,000
$250,000
$275,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,000
$5,500,000
$6,000,000
5
Insurance Type* This field is required.
Term Life Insurance
ROP-Return of Premium Term Life
Universal Life Insurance
Whole Life Insurance
Not Sure Yet
6
Term Length
Not Sure Yet
5 Year Term
10 Year Term
15 Year Term
20 Year Term
25 Year Term
30 Year Term
Greater Than 30 if Available
7
Height* This field is required.
4'-11"
5'-0"
5'-1"
5'-2"
5'-3"
5'-4"
5'-5"
5'-6"
5'-7"
5'-8"
5'-9"
5'-10"
5'-11"
6'-0"
6'-1"
6'-2"
6'-3"
6'-4"
6'-5"
6'-6"
6'-7"
6'-8"
6'-9"
6'-10"
6'-11"
7'-0"
8
Weight (in pounds)* This field is required.
9
Do You Smoke or Use Tobacco/Nicotine in ANY form?* This field is required.
Please Select
Please Select
Never
Cigarette Smoker
Quit Smoking
Cigar-Celebratory Cigar
Cigar-Occasional
Cigar-Daily
Chewing Tobacco
Marijuana
Other Tobacco or Nicotine Products
10
How Long Since You Quit Tobacco/Nicotine ?Did you know that most companies will consider you to be a smoker for 12-24 months after you quit...It is also important to note that the non-smoker rate classes will vary by company and time since you quit.
11
What Tobacco/Nicotine Do You Use?
12
Do You Take Any Medications?* This field is required.
Yes
No
13
Please include medication name, dosage and frequency takenDon't worry if you do not have exact spelling. It's most important from underwriting standpoint to know why you are taking something.
14
What Type of Diabetes Do You Have?* This field is required.
Type 1
Type 2
Gestational
15
When Were You Diagnosed With Diabetes?* This field is required.
16
What Was Your Most Recent HbA1c?
I Don't Know
Less Than 6
6.1 - 6.5
6.6 - 7.0
7.1 - 7.5
7.6 - 8.0
8.1 - 8.5
8.6 - 9.0
9.1 - 9.5
9.6 - 10.0
Greater Than 10
17
If A1C Unknown, What is Avg Blood Sugar Reading?
18
Have You Had Any of the Following?
Kidney Disease
Neuropathy
Retinopathy
Protein in Urine
Insulin Shock/Diabetic Coma
19
Provide details to your previous answer
Huge
Large
Normal
Small
Ok
Ok
20
Have you been diagnosed with or ever treated for any of the following?
Heart Disease or Any Cardiac Issues
Cancers, Tumors, Melanoma, Other Malignancies
Depression, Anxiety, Bipolar, Other Mental or Nervous Disorder
Sleep Apnea, Asthma, COPD, Chronic Bronchitis or Other Pulmonary Issue
Colitis, Crohn's, Hepatitis, Disorder of Liver, stomach or Intestines
Stroke, TIA, MS, Seizure Disorder or Any Other Disorder of Brain
Other Medical Issue
21
Exact Diagnosis, Treatment Prescribed, Approx Date Diagnosed?
22
Any Other Info You would Like to Provide?
23
If you could save money, would you consider having free exam?
YESNO
24
Name* This field is required.
First Name
Last Name
25
E-mail* This field is required.
26
Phone # (not required, but please provide if you prefer call or text)
27
Unique ID Number
28
Date Received
Date
Month
Day
Year
3
1
2
3
4
5
6
7
8
9
10
11
12
Hour
40
00
10
20
30
40
50
Minutes
PM
AM
PM
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