Racing

Racing 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
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: 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
Type of Racing:
- Automobile
- Stock Car
- Championship
- Drag
- Sports car
- Sprint
- Go-Kart
- Motorcycle - Hill climbing
- Motorcycle - Enduro
- Motorcycle - Drag
- Motorcycle - Flat track
- Motorcycle - Moto cross
- Motorcycle - Other
- Motorboat
- Snowmobile
- Other
If Other, please describe.
Number of races in last 12 months:
One to two years ago:
Lifetime:
Races planned in the next 12 months:
Date of last race:
Date Format: MM slash DD slash YYYY
Make and type of vehicle:
Formula and/or engine displacement:
Top speed:
Date Format: MM slash DD slash YYYY
Average speed:
Usual distance of race:
Do you compete for cash prizes?
- Yes
- No
Cities/towns where you race:
Describe track layout and surface:
Vehicle class:
Organization(s) which sanctions your races:
Do you plan to do any other type of racing?
- Yes
- No
If yes, give details.
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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1414 East 20th Street, Ste 8; Scottsbluff, NE 69361
(877) 564-1707
(308) 632-7404 - Office
(308) 641-6779 - Cell

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Racing

Racing Questionnaire