MAX LIFE INSURANCE COMPANY LIMITED

DIABETES QUESTIONNAIRE

Proposal No: _____________________________

Life to be Insured: ___________________________________

1. When was diabetes first diagnosed ? __________________________

2. Please give details regarding your treatment ;

a) Do you take tablets ? If “Yes”, please give the name of the tablets. Yes / No

b) Do you take insulin ? If “Yes”, please give the type of insulin Yes / No / Type / Dosage
& dosage (morning and evening).

c) Has your treatment changed in the last two years ? If “Yes”, Yes / No

please give details. _________________________

3. Do you follow a strict diet ? Yes / No

4. Regarding the monitoring of your conditions :

a) Please provide the name and address of the doctor or Name

clinic supervising your treatment. Address

b) How aften do you attend the monitoring sessions ? ________________________

c) When was your last consultation ? ________________________

d) How often do you test your blood or urine for Glucose ? Daily Weekly Monthly None

e) Please indicate your usual test results by circling as appropriate :

Blood glocose Urine glucose

Below 140 Negative

148 to 180 +

180 or more +++ or more

f) Please give dates and results of your last two HbA1c

(Glycoslated Hemoglobin) tests, if known. _________________________

5. Since your treatment began, have your ever had a diabetic Yes / No

(Hyperglycemic) or insulin (Hypoglycemic) cama. If yes,

please give complete details including dates. _________________________

6. Have you ever had any of the following :

a) Problems with your eyes. Yes / No

b) High blood pressure. Yes / No

c) Heart or circulatory trouble. Yes / No

d) Albumin or protein in urine. Yes / No

e) Numbness or tingling in your feet or legs. Yes No

If “Yes”, to any of the above, please give full details. _________________________

7. Have you lost time off work with diabetes or associated Yes / No

conditions? if “Yes” please give details including date _________________________

are duration of time off work. _________________________

8. Please provide any additional information on your condition, _________________________

which you feel will be in processing the application. _________________________

I hereby declare and agree that the above particulars and answers are complete and true, that I have not held
back any relevant facts or details, and that the answers to questionnaire will form part of the application for the
desired insurance on my life.

Signature of life to be insured Date

(If the life to be Insured in under 18 years, signature of policy Owner is required)

Max LI - AS_05062012_VER1.2