Impaired Risk Questionnaire For Race Car Driving



Race Car Driving

Race Car Driving involves 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 companies.

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*:
Applicant's   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 hold a competition license? Yes No
What racing schools has your client attended?
Is your client a professional or amateur racer? Professional Amateur
3. What racing divisions does your client participate in and who is the sanctioning body?
How often and where does your client race?
4. Please describe the car used: displacement, maximum HP, chassis and maximum speed:
5. Does your client intend to race in any other classes/divisions? Yes No
6. Additional Comments?