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Pilot Life Insurance Quote

General Information
Section 1
Pilot Information		  
Company:
First Name:
Last Name:
Street Address:
City:
State:
Zip Code:
Work Phone: Home Phone:
Email Address: Fax Number:
   
Pilot Certificate: Student Sport Private Commercial ATP
*If you are not a pilot, skip to section 2
   
Ratings: CFI IFR Glider Helicopter Multi-Engine Seaplane
Total lifetime flight hours:
Last 12 Months Total Hours Pleasure
Business Travel
For Hire
Next 12 Months Total Hours: Pleasure
Business Travel
For Hire
Have you flown or do you plan to fly: (check all that apply) Aerobatic Aircraft
Air Ambulance
Agriculture Aircraft
Employer Owned Aircraft
No Primary Instruction but other CFI work
Other Commercial Flying for Hire
Primary Instruction of Students
Have you flown or do you intend to fly outside the United States?
  Yes
  No
Do you fly experimental or Ultra-light Aircraft?
  Yes
  No
   
Section 2  
Date of Birth:
Height: Feet Inches
Weight:
Sex: Male
  Female
Do you take any prescription medications?
  Yes
  No
Have you ever had a health condition such as cancer, cardiovascular
Disease, diabetes, or any other major surgeries?
  Yes
  No
Ever used tobacco and/or nicotine products in any form?
  Yes
  No
   
Section 3  
Any cancer or heart disease in either parent on or before age 60? Yes
No
Family History  
  Age if Living Age at Death  
Mother  
Father  
Sibling  
Sibling  
   
Section 4
Policy Information		  
Policy Amount Requested: $
Term Requested: 10 Year Term
15 Year Term
20 Year Term
30 Year Term
15 Year Return of Premium
20 Year Return of Premium
30 Year Return of Premium
Universal or Whole Life
Additional Remarks or Quote Requests:
 
 
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