Diabetes questionnaire
Evidence no. (For H.O. use only)
E#
Proposed insured’s first name
Middle initial
Last name
Date of birth (dd-mm-yyyy)
Advisor’s first name
Middle initial
Last name
Advisor’s no.
–
Type of diabetes:
Date your diabetes was diagnosed (dd-mm-yyyy)
–
–
–
 Type 1
 Type 2
1. a) Weight at the time of diagnosis: lbs kg
b) In the last 12 months, have you lost more than 10 pounds (5 kgs)?  Yes  No
If ‘yes’, how much? lbs kg
2. Average number of cigarettes smoked per day:  non-smoker  less than 10  10-20  over 20
3. Is your diabetes controlled by diet alone?  Yes  No If ‘no’, list medications used.
Medication
Daily dosage
4. Do you do regular blood sugar measurements?  Yes  No
If ‘yes’, provide the last two measurements and dates.
Medication(s)
5.
Daily dosage(s)
Have you ever been told you have:
heart disease or condition?
 Yes  No
an eye abnormality?
 Yes  No
albumin or protein in urine?
 Yes  No
a kidney problem?
 Yes  No
high blood pressure?
 Yes  No
6. Have you ever been told you had an abnormal electrocardiogram?  Yes  No
7. Name and address of the doctor with complete medical records.
First name of doctor with complete records
Last name
Date last seen (dd-mm-yyyy)
–
Address (street number and name)
Apartment or suite
City
Province
Country
–
Postal code
Declaration: I declare that the answers and statements to all of the questions are complete and true and shall form part of my application for insurance on my life with the Sun Life Assurance Company of Canada (company). I understand that if I do not completely and truthfully answer all of the questions (if I misrepresent my answers or statements) the company may
void the policy.
Location signed (city)
Location signed (province)
Date (dd-mm-yyyy)
–
–
Signature of proposed insured
X
Please submit only one copy of this document. Career Sales Force
advisors: Original or fax toll-free to 1-866-487-4745.
All others: Through your MGA or National Account.
© Sun Life Assurance Company of Canada, 2012.
E269-10-12
Policy no.
For SLF use:
PIDIABQE