Sky Sports

Sky Sports 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

SKYDIVING, SKY SURFING, BASE JUMPING, PARACHUTING

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Type of Terrain	Jumps in Last 12 Months	Jumps in Last 24 Months	Jumps in Last 36 Months	Anticipated Jumps in the Next 12 Months

Date of last jump:
MM slash DD slash YYYY
Is the client a paid professional?
- Yes
- No
Is the client an instructor or in training to become an instructor and/or paid professional?
- Yes
- No
If yes, provide details:
Type of equipment used:
Any jumps outside the U.S.?
- Yes
- No
If yes, provide details:

HANG GLIDING, GLIDING, ULTRALIGHT FLYING, HOT AIR BALLOONING*

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Type of Aircraft	Type of Terrain	Maximum Flight Altitude	Total Number of Flights	Flights in Last 12 Months

*Hot air ballooning
- Tethered
- Free flight
Is the client a licensed pilot?
- Yes
- No
If yes, certificate held:
Is the client a member of a club or organization?
- Yes
- No
If yes, provide name:
Has the client or is the client expecting to participate in any record attempts, stunting events, or prototype testing?
- Yes
- No
If yes, provide details:
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