Climbing 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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pip, snuff, etc.)?YesNoFrequency:Date of last use: Date Format: MM slash DD slash YYYY Type:Kind of climbing (select all that apply): Mountain Rock Trail Ice Wall/Artificial Number of climbs:Last 12 months12-24 monthsEstimated next 12 monthsHeight of climbs on average:Highest climb ever done: Climbs Last 3 Years:Click the + sign to add additional climbs. Mountain RangesDate Climbs Next 12 months (Mountain Ranges Outside 48 Continental States)Click the + sign to add additional climbs. Mountain RangesDate Climbs Next 12 months (Mountain Ranges Inside 48 Continental States)Click the + sign to add additional climbs. Mountain RangesDate Kind of training: Date Format: MM slash DD slash YYYY Years of experience: Type of safety equipment: Date Format: MM slash DD slash YYYY Does client: Climb alone Climb with others Club affiliation(s): What class of climbing does the client most often participate in (American Rating System)? 1 2 3 4 5 Easy Moderate Difficult Severe What is the highest class the client has ever participated in?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