Military

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Military 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
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?
- Yes
- No
If yes, date of expected deployment?
Location:
Military Flying
Military Flying - Name of military organization:
Is client a pilot?
- Yes
- No
If 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:
MM slash DD slash YYYY
Does the client fly for proficient only?
- Yes
- No
If 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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(877) 564-1707
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Military

Military Questionnaire