- 5.
We thank you for applying for an HDFC Life Insurance Policy. To enable us to assess your
application, kindly send this Diabetes Questionnaire answered by the Life to be Assured and duly
signed by the Life to be Assured and Proposed Policy Holder, if any.
Please note: Wherever examples are provided, they are not intended to be complete list.
Application No / Proposal No
Name of Life to be Assured in full
1. Have you ever been diagnosed with diabetes or raised Yes / No
blood sugar? (Please answer 'Yes' or ‘No’)
Please answer all the following questions, only if the answer to above question is 'Yes'.
If the answer is 'No' then please return the form duly signed.
2. Please state the date when diabetes was first diagnosed.
3. Have you ever undergone an ECG, X-Ray, blood Yes / No
sugar test, Hba1c, blood lipid test or other
investigations?
If yes, please provide name(s) of investigation(s)
undergone and results thereof.
(Kindly attach copies of all investigation reports)
4. Kindly answer the following regarding your treatment
4. a) Do you take tablets? Yes / No
If yes, please mention name of medication, dosage and x Medication name……………………
frequency.
x Dosage………………………………
x Frequency…………………………..
4. b) Do you take insulin?
Yes / No
If yes, please mention type of insulin and details of units x Insulin Type………………………….
per day.
x Unit per day………………………….
Yes / No
4. c) Do you follow a strict diet?
5. Kindly answer the following regarding the monitoring of your condition.
5.a) Please provide the name, contact number and address
of the doctor supervising your treatment/ health condition.
5. b) How often do you consult your doctor?
5. c) How often do you test your blood and / or urine
for glucose?
HbA1c ……………………………..
5. d) Please indicate your usual test results.
Blood Glucose …………………….
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5. e) Tick if any of the along side listed is present in Glucose
urine test. Ketone
Protein
None of the above
6. Have you ever been diagnosed with any of the following? Yes No
If Yes, please tick diagnosed condition/health ailment from below list.
a. Numbness or tingling in the feet or legs e. Heart or circulatory problems
b. High blood pressure f. Retinopathy
c. Kidney problems g. Amputation or history of abscess
d. Protein or albumin in the urine h. High level of cholesterol
7. Since your treatment began, have you ever had a diabetic Yes / No
(hyperglycemic) or insulin (hypoglycemic) coma?
If yes, please mention Date of Diagnosis
Treatment Received
8. Do you smoke cigarettes/ bidis / any other form of Yes / No
tobacco etc?
If yes, how many do you smoke per day? Per day ___________ units
9. Have you ever been off work or hospitalised on account of
Yes / No
elevated blood sugar/diabetes or any complication
thereof?
If yes, please enclose copy of discharge summary.
10. Please provide any additional information apart from the
above, which will enable us in better assessment of the
application form.
An incomplete Questionnaire will not be considered valid
Declaration of Life to be Assured:
I agree and understand that the information given herein is true and complete in all respects and will form an
integral part of the proposal made by me for an insurance policy from and
that failure to disclose any material fact known to me may invalidate the contract.
Signature/thumb impression Date:…………………………….
(Life to be Assured) Place:……………………………
Signature/thumb
impression(Proposed Policy
Holder if different from Life to be Date:…………………………….
Assured) Place:……………………………
In the case of thumb impression\ signature in vernacular language:
In case of thumb impression of the Life to be Assured the same should be attested by a person of standing whose
identity can be easily established, but unconnected with the Company and this declaration should be made by him.
I hereby declare that I have explained the contents of this form to the Life to be Assured in ________ language and
have truthfully recorded the answers provided to me and that the Life to be Assured has signed /affixed thumb
impression(s) above after fully understanding the contents thereof.
Date:……………………………
Signature Place:………………………….
Name and address of the declarant
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