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Sky Sports 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.

Date of Birth: *

Age: *

Height: *

Weight: *

Ever a marijuana/THC user? *

Current marijuana/THC user? *

How is/was the marijuana or THC consumed? *

Smoked
Drops
Pills
Vape
Other

Please describe: *

Quantity used per occasion: *

How often do/did you use marijuana or THC? *

Ever a cigarette smoker? *

Current cigarette smoker? *

Date last used:

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

Please provide details for any other tobacco use:

Last date any form of tobacco was used:

Is this case being premium financed? *

Do you have a lender? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts?

Face Amount:

Are you requesting any riders?

Type of rider:

Waiver of premium
Child term rider
LTC/CI type rider
Other

Please specify:

SKY SPORTS

Select all that apply

Skydiving
Sky Surfing
Base Jumping
Parachuting

Skydiving - Type of terrain:

Skydiving - Jumps in last 12 months:

Skydiving - Jumps in last 24 months:

Skydiving - Jumps in last 36 months:

Skydiving - Anticipated jumps in the next 12 months:

Skydiving - Date of last jump:

Sky Surfing - Type of terrain:

Sky Surfing - Jumps in last 12 months:

Sky Surfing - Jumps in last 24 months:

Sky Surfing - Jumps in last 36 months:

Sky Surfing - Anticipated jumps in the next 12 months:

Sky Surfing - Date of last jump:

Base Jumping - Type of terrain:

Base Jumping - Jumps in last 12 months:

Base Jumping - Jumps in last 24 months:

Base Jumping - Jumps in last 36 months:

Base Jumping - Anticipated jumps in the next 12 months:

Base Jumping - Date of last jump:

Parachuting - Type of terrain:

Parachuting - Jumps in last 12 months:

Parachuting - Jumps in last 24 months:

Parachuting - Jumps in last 36 months:

Parachuting - Anticipated jumps in the next 12 months:

Parachuting - Date of last jump:

Is the proposed insured a paid professional?

Is the proposed insured an instructor or in training to become an instructor and/or paid professional?

Provide details:

Is the proposed insured an instructor or in training to become an instructor and/or paid professional?

Type of equipment used:

Has the proposed had any jumps outside the US?

Please provide details:

Has the proposed had any jumps outside the US?

Select all that apply

Hang Gliding
Gliding
Ultralight Flying
Hot Air Ballooning

Hang Gliding - Type of Aircraft:

Hang Gliding - Type of Terrain:

Hang Gliding - Maximum Flight Altitude:

Hang Gliding - Total Number of Flights:

Hang Gliding - Flights in Last 12 Months:

Gliding - Type of Aircraft:

Gliding - Type of Terrain:

Gliding - Maximum Flight Altitude:

Gliding - Total Number of Flights:

Gliding - Flights in Last 12 Months:

Ultralight Flying - Type of Aircraft:

Ultralight Flying - Type of Terrain:

Ultralight Flying - Maximum Flight Altitude:

Ultralight Flying - Total Number of Flights:

Ultralight Flying - Flights in Last 12 Months:

Hot Air Ballooning - Type of Aircraft:

Hot Air Ballooning - Type of Terrain:

Hot Air Ballooning - Maximum Flight Altitude:

Hot Air Ballooning - Total Number of Flights:

Hot Air Ballooning - Flights in Last 12 Months:

Is the hot air ballooning:

Tethered
Free flight

Is the proposed insured a licensed pilot?

Certificate held:

Is the proposed insured a member of a club or organization:

Please provide name(s):

Has the proposed insured participated or expecting to participate in any record attempts, stunting events, or prototype testing?

Please provide details:

Please provide additional details about the proposed insured’s medical history and provide any information that would help us negotiate the lowest rates (change in lifestyle, marriage, children, etc.):

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