EmailMeForm
Life Insurance Basic Info (DIABETIC)
Please answer each question as honestly and accurately as possible.
Don't forget to click SUBMIT.
Today's Date
MM
/
DD
/
YYYY
State of Residence
IF someone referred you to us, please tell us their name here so we can send a thank you. If no one referred you, please leave blank.
Which BEST describes your family?
Married with NO children
Married with GROWN children
Married with children UNDER 18 years old
Single with NO children
Single with GROWN children
Single with children UNDER 18 years old
YOUR Name
First
Last
YOUR Date of Birth
MM
/
DD
/
YYYY
Email
Phone
###
-
###
-
####
YOUR Age
YOUR Height
YOUR Weight
YOUR Occupation
Are you a
Smoker
Non-Smoker
How much is your monthly mortgage/rent payment?
(Knowing this helps us understand the coverage amount necessary to ensure any monthly payments would be covered).
Which type of diabetes do you have?
Type 1
Type 2
Pre-Diabetic
I don't know
At what age were you diagnosed with diabetes?
What was your last A1C number?
Mark all that are correct about your diabetes:
I am on insulin
I take 1 medication
I take 2 medications
I take 3 medications
I don't know
Please share any complications you have had (if any) as a result of your diabetes. If none, just write none.
Please mark any additional HEALTH CONCERNS you currently have or have had in the past 10 years. If you have had OTHER, please describe in the next section.
ADD/ADHD
Allergies
Anxiety
Atrial Fibrillation
Autoimmune (Rheumatoid Arthritis/ Lupus)
Bipolar
Cancer
Colitis/Crohn's Disease
COPD
Depression
GERD (gastroesophageal refulx disease)
Heart Attack
Heart Disease
High Blood Pressure
High Cholesterol
Oxygen- Are you on Oxygen?
PTSD
SELF HARM
Sleep Apnea
Stroke
Other
None of the above
If OTHER, please describe here:
Are on any MEDICATIONS? If yes, please list them here and say what they are for. For example, "Metformin for diabetes."
Please mark any that are true about your LIFESTYLE:
Have you ever struggled with Alcohol/Substance Abuse
Have you ever had a DUI
Have you ever used Marijuana
Have you had 2 or more driving violations in the past 2 years
Have you ever had you license suspended or revoked
Have you ever been convicted or are currently being charged with a felony
I have NOT had any of these
Other
If OTHER, please desribe here:
Regarding your BIOLOGICAL family, has your biological MOTHER OR FATHER been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer OR Diabetes BEFORE the age of 70?
Yes
No
I don't know
If YES, please explain here:
Regarding your BIOLOGICAL family, has any of your biological SIBLINGS been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer OR Diabetes BEFORE the age of 50?
Yes
No
I don't know
If YES, please explain here:
Have you had any major ACCIDENTS in the past 10 years? If so, please describe:
What SURGERIES have you had in the past 10 years?
Have you had any DISEASES in the past 10 years? If so, please describe:
Do you currently have a life insurance policy? If so, will this be replacing it?
What is your #1 reason for wanting to get life insurance?
Do you have a spouse or significant other?
If YES, please answer the following questions.
If NO, please skip to the end and click submit.
Yes
No
IF you have a spouse, REGARDING INCOME, mark all that apply:
The male earns more of the family income
The female earns more of the family income
BOTH earn about the same
We are retired
Spouse's Name
First
Last
SPOUSE'S Date of Birth
MM
/
DD
/
YYYY
Spouse's Age
Spouse's Height
Spouse's Weight
Spouse's Occupation
Is your SPOUSE a
Smoker
Non-Smoker
SPOUSE: Please mark any HEALTH CONCERNS you currently have or have had in the past 10 years. If you have had OTHER, please describe in the next section.
ADD/ADHD
Allergies
Anxiety
Atrial Fibrillation
Autoimmune (Rheumatoid Arthritis/ Lupus)
Bipolar
Cancer
Colitis/Crohn's Disease
COPD
Depression
Diabetes
GERD (gastroesophageal refulx disease)
Heart Attack
Heart Disease
High Blood Pressure
High Cholesterol
Oxygen- Are you on Oxygen?
PTSD
SELF HARM
Sleep Apnea
Stroke
Other
None of the above
SPOUSE: If OTHER, please describe here:
SPOUSE: Are on any MEDICATIONS? If yes, please list them here and say what they are for. For example, "Metformin for diabetes."
SPOUSE: Please mark any that are true about your LIFESTYLE:
Have you ever struggled with Alcohol/Substance Abuse
Have you ever had a DUI
Have you ever used Marijuana
Have you had 2 or more driving violations in the past 2 years
Have you ever had you license suspended or revoked
Have you ever been convicted or are currently being charged with a felony
I have NOT had any of these
Other
SPOUSE: Regarding your BIOLOGICAL family, has your biological MOTHER OR FATHER been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer OR Diabetes BEFORE the age of 70?
Yes
No
I don't know
If YES, please explain here:
SPOUSE: Regarding your BIOLOGICAL family, has any of your biological SIBLINGS been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer OR Diabetes BEFORE the age of 50?
Yes
No
I don't know
If YES, please explain here:
SPOUSE: Have you had any major accidents in the past 10 years? If so, please describe:
SPOUSE: What surgeries have you had in the past 10 years?
SPOUSE: Have you had any diseases in the past 10 years? If so, please describe:
