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Term Life Insurance for Individuals with Health Impairments

ASK THE DOCTOR
QUICK QUOTE FOR
DIABETES

INFORMATION GATHERED WILL BE USED IN THE EVALUATION OF THE INSURABILITY OF THE APPLICANT. OFFERS ARE TENTATIVE AND ARE SUBJECT TO VERIFICATION OF THE SUBMITTED MEDICAL EVIDENCE AND OTHER CRITERIA USED IN THE UNDERWRITING OF LIFE INSURANCE.© COPYRIGHT E-DIRECT INSURANCE

* Required Information

Applicant Information
* Applicant's Name:
* Date Of Birth:	00/00/0000
* Gender:	Male Female
* Height:	ft/in
* Weight:	lbs
* Occupation:
* Death Benefit:
* Type of Product:	Term Universal Whole Life Second to Die Variable
Have you ever used tobacco or nicotine products?	Yes No If yes, what type of product did you use? (Select all that apply) Cigarettes Cigar Pipe Other
Date diagnosed?
Type of medication and dosage:
Have you ever been hospitalized for diabetes?	Yes No
	When? Duration?
When did you last see your doctor?	00/00/0000
How often do you visit?
7. Do you have glycohemoglobin AIC tests done?	Yes No
	Result
Do you test your own sugar?	Yes No
Do you know the most recent result?	Yes No
When?
Date of last blood glucose level:	00/00/0000
Result:
Are you and your doctor pleased with your control?	Yes No
Have you had any kidney problems?	Yes No
Any protein in the urine?	Yes No
Have you had any problem with your eyes?	Yes No
Any treatment?	When?
Any high blood pressure?	Yes No
	When? 00/00/0000
Any "heart trouble"?	Yes No (If Yes, Please complete the Heart Questionnaire also.)
	When? 00/00/0000
Any neurological symptoms, loss of feeling in your feet?
Additional Comments?
Please fill out all information completely and accurately.

E-DIRECT INSURANCE.
11/ 01/ 2005
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