Military 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 Branch of military: Army Marines Navy Reserves Air Force National Guard Coast Guard Special Forces: Army Rangers U.S. Army Special Forces (aka The Green Berets) Delta Force Navy SEAL or Navy Special Warfare Development Group Air Force Special Forces Marine Corps Force Reconnaissance (Force Recon or FORECON) Stationed where: List all duties: Years of service: Military pay grade: Are you aware of any upcoming deployment plan or do you currently have orders in hand for deployment?YesNoIf yes, date of expected deployment?Location: Military Flying Military Flying - Name of military organization: Is client a pilot?YesNoIf no, specify capacity in which the client flies: Type of aircraft flown:How long has the client been flying in this kind of aircraft (if less than one year, also specify aircraft previously flown): Date of last flight: Date Format: MM slash DD slash YYYY Does the client fly for proficient only?YesNoIf yes, provide number of hours on proficiency flying per year: 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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