800.869.1DBS

We make doing business easier and more profitable for you.

Home
Contact
File Upload
Login

About US
Products
The DBS Distinction
Services

Close Menu

Diabetes Underwriting Questionnaire

Agent's Name: *

First

Last

Agent's Phone Number: *

Agent's Email: *

State of Issue/Delivery: *

Send to Additional Email?

Proposed Insured's Name: *

First

Last

Sex: *

Male
Female

What is the proposed insured's: *

Date of Birth
Age

Please select "age" if the date of birth is unknown.

Date of Birth: *

Age: *

Height: *

Weight: *

Ever a marijuana/THC user? *

Current marijuana/THC user? *

How is/was the marijuana or THC consumed? *

Smoked
Drops
Pills
Vape
Other

Please describe: *

Quantity used per occasion: *

How often do/did you use marijuana or THC? *

Ever a cigarette smoker? *

Current cigarette smoker? *

Date last used:

Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) *

Please provide details for any other tobacco use:

Last date any form of tobacco was used:

Is this case being premium financed? *

Do you have a lender? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts?

Face Amount:

Are you requesting any riders?

Type of rider:

Waiver of premium
Child term rider
LTC/CI type rider
Other

Please specify:

Diabetes

Date of diagnosis: *

Age at Onset:

Type of Diabetes: *

Type I (Juvenile)
Type II (Adult)

It is very important to have these numbers below for any useful pre-underwriting premium estimate.

Most current A1C test reading: *

Date: *

How often does the proposed insured visit their physician for a diabetic checkup?

Monthly
Every 3 months
Every 6 months
Annually
Less than annually

The accuracy of the information below is important in assessing your client’s potential rating.

The proposed insured controls their diabetes by:

Diet
Regular Exercise
Oral Medication
Insulin
Insulin Pump

Check all that apply

Indicate type and frequency:

Regular Exercise

Indicate medication, dosage frequency

Oral Medication

Units per day:

Insulin

Has the proposed insured’s treatment been changed in the last 2 years?

Please provide details:

Does the proposed insured take any medications (prescription or otherwise) at this time?

Medication 1:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 2:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 3:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 4:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 5:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

More than five medications?

Name of Medication (Prescription or Otherwise), Date Started Using, Date Stopped Using, Quantity Taken, and Frequency Taken:

Other Recent Readings

Blood Sugar reading:

Microalbumin level:

Blood Pressure:

Triglycerides:

LDL (bad cholesterol):

HDL (good cholesterol):

Has the proposed insured experienced any of the following?

Weight Problems
High blood Pressure
Chest Pain
Insulin shock
Coronary Artery Disease
Elevated lipids
Diabetic Coma
Abnormal ECG
Neuropathy (Nerve Pain)
Retinopathy (Eye)
Kidney Disease
Alcohol/Drug abuse
Protein in the Urine
Glycosuria (Sugar in Urine)
Other

Please explain:

Weight Problems

Please explain:

High blood Pressure

Please explain:

Chest Pain

Please explain:

Insulin shock

Please explain:

Coronary Artery Disease

Please explain:

Elevated lipids

Please explain:

Diabetic Coma

Please explain:

Abnormal ECG

Please explain:

Neuropathy (Nerve Pain)

Please explain:

Retinopathy (Eye)

Please explain:

Kidney Disease

Please explain:

Alcohol/Drug abuse

Please explain:

Protein in the Urine

Please explain:

Glycosuria (Sugar in Urine)

Other (Describe):

Please explain:

Other

Please provide additional details about the proposed insured’s medical history:

Free Aftersales Support

We offer 100% free after sales support. Once you purchase you can use our Support Forum backed by professionals who are available to help our customers.

Visit Support Forum

Customization Services

We provide WordPress customization services some of which are:

Theme install and set-up
Responsive development
Custom page templates
Custom plugin development
Custom theme and icons design

Blog Categories

New Releases
Update Info

Explore Our Items

CSS3 Solutions
Icon Sets
PHP Scripts
Site Templates
WordPress Plugins
WordPress Themes

CONTACT US

Diversified Brokerage Services, Inc.

5501 Excelsior Blvd
Minneapolis, MN 55416
Phone 800.869.1DBS / 952.697.5000
Fax 952.697.5001

CONNECT WITH US

New to DBS? Register Here

Join our Team

LEARN WITH US

Blog

Website is for agent use only. Not for use with the general public. Privacy Policy | Terms of Use

Securities offered through The Leaders Group, Inc. Member FINRA/SIPC. 26 W. Dry Creek Circle, Suite 800, Littleton, CO 80120, 303.797.9080. Diversified Brokerage Services is not affiliated with The Leaders Group, Inc.

Before investing, research the background and registration status of any firm or financial professional you are considering dealing with at: http://brokercheck.finra.org/