Moseleymcgill – 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

Client Name

Date of Birth

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:

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