Foreign Travel 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 CLIENT Occupation Company: Income: Location of work and duties: Citizenship: U.S. Visa type and expiration: Current residence: Primary residence: Location of primary care physician: TRAVEL: PRIOR 12 MONTHS (list all travel)Click the + sign to add more travel. City/CountryReasonNumber of Trips/DatesTotal Days TRAVEL: NEXT 12 MONTHS (list all travel)Click the + sign to add more travel. City/CountryReasonNumber of Trips/DatesTotal Days 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