Racing 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 MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas 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: MM slash DD slash YYYY Make and type of vehicle: Formula and/or engine displacement: Top speed: 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 Δ