Foreign Travel

Foreign Travel 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, 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/Country Reason Number of Trips/Dates Total Days
TRAVEL: NEXT 12 MONTHS (list all travel)
Click the + sign to add more travel.
City/Country Reason Number of Trips/Dates Total 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

City/Country	Reason	Number of Trips/Dates	Total Days

City/Country	Reason	Number of Trips/Dates	Total Days