TataAIA/NB/DM/87.

Diabetes Customer Questionnaire

Name Of Proposed Insured: .......................................................................................................................

Policy no.: ................................................................................... Dated: ................................................

1) Date of first diagnosis? ……/……/……

2) Name of main doctor attended for diabetes?

........................................................................................................................................................

3) Date you last attended the doctor for this condition?

...........................................................................................................................................................

4) a) Do you still receive treatment or suffer from any symptoms? Yes No

If No, then how long has it been since you have ceased all treatment and have been free of all
symptoms?
______year _______month
............................................................................................................................................................

5) Do you use insulin injections? Yes No

If Yes, how many injections per day ? 1 2 3 4
How many units per day? 0-30 31-50 >50

6) Do you take oral medication for Diabetes? Yes No

If Yes, give name of tablets and dose?
........................................................................................................................................................

7) Do you undergo test for monitoring Blood sugar? Yes No

If Yes, what was the last fasting blood sugar/HBAc reading and when was it tested?
.......................................................................................................................................................

8) Do you suffer from any of the Following

Yes No

Eye problems related to diabetes

Protein in the Urine or kidney Disease
Neuropathy or Nerve disorder
High cholesterol of triglycerides
High blood pressure
Heart condition or Circulatory trouble
Non healing ulcers or wound

Tata AIA Life Insurance Company Limited

(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/239
TataAIA/NB/DM/87.1

9) Have you been hospitalized for control of high blood sugar? Yes No
If Yes, please provide details including dates (month/year).
..............................................

10) Since your treatment began, have you ever been hospitalized for diabetic coma or any condition
related to diabetes? Yes No
If Yes, please provide dates and also submit copies of hospitalization records of the episode(s).

…………………………………………………………………………………………………….

I hereby declare and agree that the above particulars and answers are complete and true, and this
questionnaire will form part of the contract of the desired insurance of my life. I hereby irrevocably
authorize any organization, institution or individual that has any record or knowledge of my/the insured’s
health and medical history to disclose such information or provide such medical records to Tata AIA.

Signature of Proposed insured: ______________________ Date: ____________________

Signature of Applicant: ______________________ Date: ____________________

(If applicant is different from the proposed insured)

VERNACULAR DECLARATION:
In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.

I__________________ holding ______________(ID card type) with number __________(ID card

number) hereby declare that I have explained the contents of this declaration to the Proposed
Insured/Applicant in ________________ language and that the Proposed Insured/Applicant has affixed
his/her signature/thumb impression after fully understanding the contents thereof.

________________________________ _____________________
Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature

Tata AIA Life Insurance Company Limited

(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/239