Climbing

Climbing 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
MM slash DD slash YYYY
Client Name
Date of Birth
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, pip, snuff, etc.)?
- Yes
- No
Frequency:
Date of last use:
MM slash DD slash YYYY
Type:
Kind of climbing (select all that apply):
- Mountain
- Rock
- Trail
- Ice
- Wall/Artificial
Number of climbs:
Last 12 months 12-24 months Estimated next 12 months
Height of climbs on average:
Highest climb ever done:
Climbs Last 3 Years:
Click the + sign to add additional climbs.
Mountain Ranges Date
Climbs Next 12 months (Mountain Ranges Outside 48 Continental States)
Click the + sign to add additional climbs.
Mountain Ranges Date
Climbs Next 12 months (Mountain Ranges Inside 48 Continental States)
Click the + sign to add additional climbs.
Mountain Ranges Date
Kind of training:
MM slash DD slash YYYY
Years of experience:
Type of safety equipment:
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

Mountain Ranges	Date

Mountain Ranges	Date

Mountain Ranges	Date

Climbing

Climbing Questionnaire