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Guaranteed Life Insurance

Straightforward | Efficiency Focused

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Life Insurance Carrier Quotes
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INTERNAL RATE OF RETURN ON DEATH BENEFITS (IRR)
UNDERWRITING, IMPAIRED RISK & HEALTH ASSESSMENTS
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THE PURE SOLUTION
THE PURE COMPARISON
PRIVACY POLICY

Life Insurance Nerds

Guaranteed Life Insurance

Straightforward | Efficiency Focused

Life Insurance Carrier Quotes
Life Expectancy Calculators
INTERNAL RATE OF RETURN ON DEATH BENEFITS (IRR)
UNDERWRITING, IMPAIRED RISK & HEALTH ASSESSMENTS
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
PRIVACY POLICY

Life Insurance Nerds

Guaranteed Life Insurance

Straightforward

Efficiency Focused

ABOUT
Contact
LIFE SETTLEMENTS
THE PURE SOLUTION
THE PURE COMPARISON
INTERNAL RATE OF RETURN (IRR)
LIFE EXPECTANCY CALCULATORS
UNDERWRITING, IMPAIRED RISK & HEALTH
PRIVACY POLICY

Diabetes Questionnaire

DATE

ADVISOR NAME

PHONE ex. 555-555-1212

FAX ex. 555-555-1212

Client Information

PROPOSED INSURED

DATE OF BIRTH

Male Female

STATE OF SALE

HEIGHT:

WEIGHT:

TOBACCO USE:

Yes No Quit

QUIT, WHEN?

OTHER COMPANY ACTIONS:

RATED

Rated

TABLE

POSTPONED/DECLINED

Postponed Declined

OTHER COMPANY DETAILS:

AGE AT ONSET OF DIABETES:

TYPE OF DIABETES

TYPE I TYPE II

WHAT IS THE METHOD OF CONTROL?

DIET ONLY DIET AND INSULIN INJECTIONS DIET AND ORAL MEDICATION

PLEASE LIST MEDICATIONS:

HOW MANY TIMES PER DAY IS INSULIN ADMINISTERED?

I AM ON AN INSULIN PUMP ONE OR TWO TIMES PER DAY THREE OR MORE TIMES PER DAY

UNITS OF INSULIN PER DAY

HOW OFTEN DO YOU MONITOR SUGAR LEVELS?

ONE OR TWO TIMES PER DAY THREE OR MORE TIMES PER DAY

IN THE LAST 6 MONTHS HAVE YOU HAD A GLYCOHEMOGLOBIN (A1C) TEST?

Yes No

AVERAGE A1C FOR THE PAST 6 MONTHS?

AVERAGE A1C FOR THE PAST 12 MONTHS?

HOW LONG HAS THE GLYCOHEMOGLOBIN LEVEL REMAINED CONSTANT?

0 TO 6 MONTHS 6 TO 12 MONTHS 13 MONTHS OR MORE

PLEASE INDICATE BELOW IF YOU HAVE ANY OF THE FOLLOWING. CHECK ALL THAT APPLY.

EKG ABNORMALITIES INSULIN REACTIONS DIABETIC COMA ANY EYE TROUBLE HEART TROUBLE/CAD/PVD PROTEIN IN URINE SKIN ULCERATIONS AMPUTATIONS NEUROPATHY OR LOSS OF FEELING OTHER:

OTHER?

ARE YOU RECEIVING TREATMENT OR ARE YOU UNDER SUPERVISION?

Yes No

WHEN WAS THE LAST TIME YOU VISITED A PHYSICIAN?

0 TO 6 MONTHS 6 TO 12 MONTHS 12 TO 24 MONTHS MORE THAN 24 MONTHS

INDICATE MOST RECENT BLOOD PRESSURE READING WITH OR WITHOUT MEDICATION (TO THE BEST OF YOUR KNOWLEDGE):

B.P.

B.P. MEDICATIONS:

DO YOU EXERCISE 3 OR MORE TIMES PER WEEK ON A REGULAR BASIS?

Yes No

IF YES, WHAT TYPE OF EXERCISE?

HAS EITHER PARENT OR ANY SIBLING DIED BEFORE AGE 65, OTHER THAN BY ACCIDENT?

No Yes

CAUSE OF DEATH?

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Life Insurance Nerds Corporate Division

2155 Butterfield, Suite 102 South

Troy, MI 48084

877-637-3717

info@lifeinsurancenerds.com

HOME
ABOUT
BLOG
Contact

HOME
ABOUT
BLOG
Contact

Calculators
Assessments
IRR

Calculators
Assessments
IRR

LIFE SETTLEMENT
The PURE Comparison
The PURE Solution

LIFE SETTLEMENT
The PURE Comparison
The PURE Solution