PILOT LIFE INSURANCE QUOTE FORM

Section 1
Pilot Information

Company
 *
Last Name
*
First Name
*
Street Address
*
City
 *
State *
Zip *
Work Phone
*
Home Phone
*
E-mail
 *
Fax
 *
Pilot Certificate:
 *
  *If you are not a pilot, skip to section 2
Ratings:
 *
Total lifetime flight hours:
 *  
Last 12 Months Total Hours:

Pleasure: * Business Travel: * For Hire: *

Next 12 Months Total Hours:

Pleasure: * Business Travel: * For Hire: *

In the past 3 years have you flown (check all that apply):
*
  Please describe the type of flying/aircraft and the annual hours of each item checked
*
Have you flown or do you intend to fly outside the United States?
 *
 

 If yes, explain:
*
Section 2  
Date of Birth: *
Height:
 * Feet * Inches
Weight:
 *

Sex:

*

Do you take any prescription medications?
 *
 

 If yes, explain:
*
Have you ever had a health condition such as cancer, cardiovascular Disease, diabetes, or any other major surgeries? *
  If yes, explain:
*
Tobacco Use:
 Do you currently use tobacco in any form?*
  If you are a former Tobacco user, when did you quit?*

*Not a current smoker, Skip to section 3
 

 What form of Tobacco: *
 

 How many annually?*
Section 3  
Any Cancer or Heart Disease in either parent on or before age 60?
 * *
 

 If yes, explain:
*
Family History:
    
  Age if Living If Deceased
Mother:
 * *
Father:
 * *
Sibling:
 * *
Sibling:
 * *

Section 4  
Policy Information  
Policy Amount Requested: * Term Requested: *

Additional Remarks or Quote Requests:
  *
How did you hear about us?
  *