Sky Sports 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 SKYDIVING, SKY SURFING, BASE JUMPING, PARACHUTINGClick the + sign to add more rows. Type of TerrainJumps in Last 12 MonthsJumps in Last 24 MonthsJumps in Last 36 MonthsAnticipated 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 AircraftType of TerrainMaximum Flight AltitudeTotal Number of FlightsFlights 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 Δ