Aviation

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Aviation Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
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HOURS FLOWN AS A PILOT OR COPILOT
Hours flown as a pilot or copilot
Student
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
Private
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
Scheduled Passenger Airline
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
Full-time Company
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
Non-scheduled or Charter
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
Crop Dusting or Aerial Spraying
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
Student Instruction
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
Military
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
Other
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
If other, please describe:
Total logged hours:
Type of flying 1-2 years ago Last 12 months Estimate next 12 months
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.
Date of last flight:
Date Format: 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:
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CIVILIAN FLYING
Civilian Flying: Has the client flown or do they intend to fly outside the US?
- Yes
- No
If yes, provide details:
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MILITARY FLYING
Military 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:
Date Format: 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:
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.
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

Aviation

Aviation Questionnaire

Hours flown as a pilot or copilot