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Step 1 - Agent Information *Your Name *Your Company Address City State please choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Your Phone *Your Email Step 2 - Pilot Information *State please choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Sex Male Female *Date of Birth month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 *Height feet 4' 5' 6' 7' inches 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11" *Weight lbs *Pilot Status or Certificate Non-Pilots choose "Not a pilot" and skip to Step 3 please choose ATP Commercial Light Sport Pilot Private Recreational Student Pilot Not a pilot   Ratings Instrument CFI Seaplane Helicopter Multi Engine Glider Please enter whole numbers only *Total Time Hours flown in the Past 12 Months   In the past 3 years, has your client flown: (Please check all that apply) Primary Instruction of Students No Primary Instruction but other CFI work Aerobatic Aircraft Agriculture Aircraft Air Ambulance Experimental and/or Homebuilt Offshore Helicopter Ultralight Aircraft Step 3 - Policy Information *Policy Amount Requested please choose 100,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000 500,000 550,000 600,000 650,000 700,000 750,000 800,000 850,000 900,000 950,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000 5,500,000 6,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000 9,000,000 9,500,000 10,000,000+     *Term Requested please choose 30 Year Level Term 20 Year Level Term 15 Year Level Term 10 Year Level Term Step 4 - Health *Has your client ever had a health condition that would affect the underwriting of this policy? No     Yes   *Does your client take any prescription Medications? No     Yes   *Has your client used any tobacco or nicotine products? Never Quit month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec year 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Smokes Cigarettes, less than a pack per day Smokes Cigarettes, more than a pack a day Smokes Cigars occasionally - less than 12 annually Smokes Cigars more than 12 annually Uses a Smokeless Tobacco, Pipe, Nicotine Patch or Gum   *Has there been any occurrence of cardiovascular disease or cancer before the age of 60 in your clients' natural parents or siblings? No     Yes Any Additional Comments?