Aviation Questionnaire

Aviation Questionnaire

SECTION I: AGENT INFORMATION
Full Name of Agent:
Agent's Phone Number
Agent's Fax Number
Agent's E-mail

SECTION II: CLIENT BACKGROUND INFORMATION
Client's Name
Date Of Birth:
Sex:	Male Female
Smoker:	Smoker Non-smoker
If history of smoking, date stopped?:
Occupation? (if not currently employed explain - ie: disabled, Social Security Disability Workman's Comp., etc.)
Type of product:
Face amount requested?
Premium Range Desired? (If replacement, list current premium and face amount)

SECTION III: CLIENT MEDICAL INFORMATION
Prior company action? (Name of company, rating, premium)
Type of medical impairment or other underwriting problem?
Date condition was first diagnosed?
Current height and weight? (If weight has changed in the last 12 months, please indicate)
Current blood pressure readings?
Name all medications currently being taken. Include dosage and frequency. (ie: 25mg. 2X per day)
Is client currently seeing a doctor for listed condition? Date of last visit?
Types and dates of surgery or hospital treatment?
Has any immediate relative (father, mother, sister, brother) died prior to age 60 of heart disease, diabetes complications, or cancer?
Any other medical history?

SECTION IV: AVIATION QUESTIONS
How many total hours flown?
How many solo hours flown?
How many hours flown within the last 12 months? Please specify and differentiate the number of hours for business and / or personal use.
How many hours expected to fly in the next 12 months? Please specify and differentiate the number of hours for business and / or personal use
If business use, specify type of business. (ie: commercial or charter).
Where does client fly to?
Does client have Instrument flight rating or Airline Transport certificate?
Is client an active instructor?
What type of aircraft and how many engines?

After we receive your information and if we have no further questions, we will be back to you within 48 hours with an Inst-A-Quote^TM on your client, proposals, and a formal application to write your case. Thank you for using our exclusive Inst-A-Quote^TM service.