Impaired Risk Questionnaire For Pilot




Pilots involve impaired risk underwriting, where a person whose physical condition is less than standard or
who has a hazardous occupation or hobby, to help obtain the best tentative offers by several top rated life insurance

Please submit a completed form below to shop for the best possible premium:

* required information      **Please use TAB key to proceed to the next question field, not the ENTER key.**

Agent's Name*:
Phone Number*:
E-Mail Address*:
Date Of Birth:
Sex: Male Female
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Has your client 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. Does your client have an Instrument Flight Rating? Yes No
3. What level of license/certificate does your client hold?
4. Is your client's FAA medical certificate current? Yes No
5. How many total hours has your client flown?
6. What is the purpose of your client's flying?
How many hours did your client fly last year?
How many planned for next year?
What type(s) of aircraft does your client fly?
Date of last flight:
7. Additional Comments?