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Hazardous Occupation

Hazardous Occupation 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
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 stay
Type of water
Type of vessel
Size 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

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Moseley McGill, LLC is a Marketing Firm assisting Insurance Professionals in Estate Creation, Protection and Preservation, Quoting Services, Advanced Case Design and Case Management.

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1414 East 20th Street, Ste 9; Scottsbluff, NE 69361
(877) 564-1707
(308) 632-7404 - Office
(308) 641-6779 - Cell

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