DIABETES

Please complete the following information:
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    Broker Information:
    Broker Name: *

    Phone: *

    Fax: *

    Email: *

    Address: *

    City: *

    State: *

    Zip: *

    Client Information:
    Insured's Name:

    Date of Birth:

    Sex:
    Male Female
    Type of Policy:

    State(s):

    Nicotine User:
    YES NO
    If YES: Cigarette Cigar Other:

    If NO: Number of years without:

  • Age of onset?
  • Diabetes is controlled by? (diet, oral medication or insulin)
  • Other medications?
  • Recent blood sugar reading?
  • Does your client monitor their own blood sugar?
    YES NO
  • Most recent glycohemoglobin (HbA1c) or fructosamine level?
  • Please indicate if your client has had any of the following:
    (Use the CTRL key to select more than one)
  • Any other major health problems?
  • Additional Comments: