Pilot Questionnaire                 

Pilot involves impaired risk underwriting.  Obtain a tentative life insurance offer by completing the form below: * required information **Please use TAB key to proceed to the next question field, not the ENTER key.**


Applicant's Name*:

Applicant's Address*:
Applicant's Phone Number*:
Applicant's E-Mail Address*:
Date Of Birth:
Sex: Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Have you ever used tobacco or nicotine products? Yes No
If yes, what type of product did you use? (Select all that apply)
Cigarettes Cigar Pipe Other
2. Do you have an Instrument Flight Rating? Yes No
3. What level of license/certificate do you hold?
4. Is your FAA medical certificate current? Yes No
5. How many total hours have you flown?
6. What is the purpose of your flying?
How many hours did you fly last year?
How many planned for next year?
What type(s) of aircraft do you fly?
Date of last flight:
7. Additional Comments?