Hazardous Occupation 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, pipe, snuff, etc)?YesNoFrequencyDate of Last UseType Law enforcement Armed car guard Bank guard Municipal police Motorcycle police Penal guard Border patrol Fishery officer Federal agencies FBI DEA DIA SWAT Federal Air Marshall Secret Service SCIS Bomb disposal crew Fisherman: Type of fishing Crab Lobster Crocodile Other If Other, please describe:Length of stayType of waterType of vesselSize of vessel Other Building/Construction Mining/Quarrying Mountain blasting Oil/Natural Gas Oil/Natural Gas On-shore exploration drilling/production Oil/Natural Gas Off-shore drilling/production Metal industry Lumber industry Other If Other, please describe:Job Title:Description/Duties: 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