Aviation Underwriting Questionnaire

Agent's Name: *

First

Last

Agent's Phone Number: *

Agent's Email: *

State of Issue/Delivery: *

Send to Additional Email?

Proposed Insured's Name: *

First

Last

Sex: *

Male
Female

What is the proposed insured's: *

Date of Birth
Age

Please select "age" if the date of birth is unknown.

Height: *

Weight: *

Ever a marijuana/THC user? *

Ever a cigarette smoker? *

Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) *

Is this case being premium financed? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts?

Are you requesting any riders?

Aviation

Please note: These cases will need to be quick quoted so please allow time for this process to be completed.

Does the proposed insured fly:

Commercial (flying for pay)
Non-commercial (not for pay)

Check all that apply

Logged Hours:

Total Lifetime hours

Solo Lifetime hours

Commercial hours

Private hours

Licensing, Rating, and FAA Medical Information

Certificate License (select all that apply):

Student
Private Pilot
Commercial

Do you have an Instrument Flight Rating (IFR)?

Does the proposed have any FAA violations?

Class of FAA Medical Certificate held:

Date of last FAA medical exam:

Does your medical certificate specify any limitations?

Non-Military Flying

Do you use other than public airports?

Have you flown or do you intend to fly outside the US?

Have you flown or do you intend to fly a prototype, experimental, personally built aircraft, rotorcraft, balloon or glider?

If an aerial applicator, is aircraft specifically built for aerial application?

Have you engaged in or do you contemplate engaging in any kind of flying not indicated above?

Military Flying

Military Flying?

Coverage Preference

If given a choice of the following, which ONE option would you prefer?

Pay additional premium coverage unrestricted by aviation activities
Aviation exclusion included to exclude coverage for aviation activities

Does the proposed insured take any medications (prescription or otherwise) at this time?

Please provide additional details about the proposed insured’s medical history:

Save and Resume Later