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
Click the + sign to add more rows.
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*
Click the + sign to add more rows.
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:
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

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

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

Sky Sports

Sky Sports Questionnaire