Diabetes Questionnaire Form Page 2
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1
26.
Have you ever experienced any of the followings:
If “Yes”, please provide details.
(a) Eye problem
Yes ____
No___
_________________________________________________________________________________________
(b) High blood pressure
Yes ____
No___
_________________________________________________________________________________________
(c) Urine abnormalities/kidney problem
Yes ____
No___
_________________________________________________________________________________________
(d) Numbness/pain of legs and feet
Yes ____
No___
_________________________________________________________________________________________
(e) Chest pains
Yes ____
No___
_________________________________________________________________________________________
(f) Heart problem
Yes ____
No___
_________________________________________________________________________________________
7. Have you ever been hospitalised due to this condition?
Yes ____
No___
If “Yes”, please state the date of admission, duration of stay and full name of hospital.
_________________________________________________________________________________________
8. Have you ever had a diabetic coma?
Yes ____
No___
If “Yes”, please state the date(s) and frequency of having such coma.
_________________________________________________________________________________________
9. Please provide full name and address of the doctor whom you have consulted for this condition.
_________________________________________________________________________________________
I declare that to the best of my knowledge and belief, the information given by me is true and complete and that
no material facts (i.e. facts likely to influence the assessment and acceptance of my proposal for the life insurance)
have been withheld.
I agree that this form shall constitute a part of my proposal for Life Insurance with HSBC Insurance (Singapore)
Pte. Limited.
__________________________________
__________________________________
Signature of life insured/participant
Signature of policyowner/certificate holder
(if other than life insured/participant)
Date: _____________________________
Date: _____________________________
Page 2 of 2
HSBC Insurance (Singapore) Pte. Limited
10 Eunos Road 8, #11-01 Singapore Post Centre (South Lobby), Singapore 408600
Tel: (65) 6225 6111 Fax: (65) 6221 2188
Web site:
Company registration no. 195400150N
SGI NB SUQ_v1.0 May 2011
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