| SECTION
I: AGENT INFORMATION
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Full Name of Agent: |
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Agent's Phone Number |
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Agent's Fax Number |
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Agent's E-mail |
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| SECTION
II: CLIENT BACKGROUND INFORMATION |
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Client's Name |
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Date
Of Birth: |
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Sex: |
Male
Female
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Smoker: |
Smoker
Non-smoker
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If history of smoking, date stopped?: |
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Occupation? (if not currently employed explain - ie: disabled, Social Security Disability Workman's Comp., etc.) |
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Type of product: |
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Face amount requested? |
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Premium Range Desired? (If replacement, list current premium and face amount) |
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| SECTION
III: CLIENT MEDICAL INFORMATION |
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Prior company action? (Name of company, rating, premium) |
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Type of medical impairment or other underwriting problem? |
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Date condition was first diagnosed? |
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Current height and weight? (If weight has changed in the last 12 months, please indicate) |
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Current blood pressure readings? |
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Name all medications currently being taken. Include dosage and frequency. (ie: 25mg. 2X per day) |
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Is client currently seeing a doctor for listed condition? Date of last visit? |
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Types and dates of surgery or hospital treatment? |
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Has any immediate relative (father, mother, sister, brother) died prior to age 60 of heart disease, diabetes complications, or cancer? |
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Any other medical history? |
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| SECTION IV: DIABETES QUESTIONS |
| Definition: A metabolic disease where carbohydrate utilization is reduced and lipid and protein enhanced; it is caused by either a deficiency of insulin normally secreted by the pancreas or by resistance to the body's insulin. Onset under age 20 is considered “juvenile onset”. |
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Date and age of onset? |
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Type(s) of treatment? Diet, oral medication, or insulin? |
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If insulin dependent, give the number of units taken, the types taken (ie: Regular, Lente, NPH, Humalog) and times of day taken? If oral medication(s) give dosage and type(s). |
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Has client ever had problems with eyes (Retinopathy), circulation, numbness or tingling in the hands and feet (Neuropathy), infections or kidney problems? If “Yes,” give Date(s)? |
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Does proposed insured test his blood on a regular basis? If “Yes,” how often and what are the usual results? |
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Is client under good control? Has client ever been in a diabetic coma? If “Yes,” Date(s)? |
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How often does client visit doctor? Date of last visit? |
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Date and result of last fasting blood glucose and/or glycohemoglobin A1C reading? |
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