Aviation QuestionnairePlease answer all questions applicable to the client's medical history. Questions? Call Jim or Teresa at 877.564.1707. Producer Name* Phone* Email* Date MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)? Yes No Frequency Date of Last Use Type ********************************************************************************HOURS FLOWN AS A PILOT OR COPILOTHours flown as a pilot or copilotStudentType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsPrivateType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsScheduled Passenger AirlineType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsFull-time CompanyType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsNon-scheduled or CharterType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsCrop Dusting or Aerial SprayingType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsStudent InstructionType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsMilitaryType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsOtherType of flying1-2 years agoLast 12 monthsEstimate next 12 monthsIf other, please describe: Total logged hours:Type of flying1-2 years agoLast 12 monthsEstimate next 12 months********************************************************************************.Date of last flight: MM slash DD slash YYYY Type of licenses: Student Private Commercial ATP Other If other license, please describe: Do you have an Instrument Flight Rating (IFR)? Yes No Types of Aircraft: Civilian Prop or jet Helicopter Hot air balloon Glider Experimental Other If other, please describe: Types of Aircraft: Military Fighter Bomber Transport or Cargo Helicopter Reconnaissance Experimental Other If other, please describe: Describe any unusual aviation activity:********************************************************************************CIVILIAN FLYINGCivilian Flying: Has the client flown or do they intend to fly outside the US? Yes No If yes, provide details: ********************************************************************************MILITARY FLYINGMilitary flying: Name of military organization: Is the client a pilot: Yes No If no, specify capacity in which the client flies: Type of military aircraft flown: How long has the client been flying in this kind of aircraft (if less than one year, also specify aircraft previously flown) Date of last flight: MM slash DD slash YYYY Does the client fly for proficiency only? Yes No If yes, provide number of hours on proficiency flying per year: ********************************************************************************.If given a choice of the following, which would the client prefer? Pay additional premium for coverage unrestricted by aviation activities Have an aviation exclusion included in the policy to exclude coverage for aviation activities For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2017 Tellus Brokerage Connections Δ