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Step 1: Your Information
Step 1: Your Information
Step 1: Your Information
First Name
M.I.
Last Name
Gender
Male
Female
Date of Birth
State of birth (Country if not U.S.)
Residence Address
City
State
Zip Code
Email Address
Home Phone
Work Phone
Cell Phone
Is the Proposed Insured a permanent, legal US Resident?
Yes No
Occupation
Employer
Business Address
City
State
Zip Code
Step 2: Policy Type
Step 2: Policy Type
Step 2: Policy Type
Amount of Insurance $  
Guarantee Period
10 Years
15 Years
20 Years
30 Years
Permanent
Purpose of Insurance is
Personal
Business
Executive Benefit
Estate Planning
Do you currently have any life insurance?
Yes No
Will this policy replace any life insurance?
Yes No
Primary Beneficiary
Relationship
Contingent Beneficiary
Relationship
Step 3: Medical History
Step 3: Medical History
Step 3: Medical History
In order to determine your insurability we need to ask you some medical questions. All of this information is privileged and will be protected under applicable HIPPA non disclosure laws.
Your Height
ft. in.
Your Weight
lbs.

Family History

Father
Age if Living
or
Age at Death
Mother
Age if Living
or
Age at Death
Have any immediate family members (mother, father, brother, sister) been diagnosed with or died from coronary artery disease, cerebrovascular disease, diabetes or cancer before age 70?
Yes No
Has a member of the medical profession ever treated you for or diagnosed you with:
1)
high blood pressure, chest pain, a heart attack, coronary artery disease, a heart valve disorder, a heart murmur, an irregular heart beat, cerebrovascular disease, a stroke, circulatory disease, an aneurysm or any disease of the heart or blood vessels?
Yes No
2)
anemia or other abnormality of the blood (other than HIV)?
Yes No
3)
a polyp, cyst, tumor, cancer, leukemia, melanoma, lymphoma or Hodgkin’s disease?
Yes No
4)
diabetes, high blood sugar, glucose intolerance or other endocrine disorder?
Yes No
5)
anxiety, depression, or any other mental or psychiatric illness?
Yes No
Has a member of the medical profession ever treated you for or diagnosed you with:
1)
an infection caused by the Human Immunodeficiency Virus (HIV) (Not applicable in CA. In WI: AIDS virus, HIV antibody testing is limited to FDA-licensed enzyme immunoassay and confirmatory HIV antibody tests. Any test performed at an anonymous counseling and testing site or home testing is confidential and need not be revealed on this application.), Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or any other sexually transmitted disease?
Yes No
2)
asthma, emphysema, cystic fibrosis, sleep apnea, sarcoidosis, tuberculosis or any other disorder of the lungs or respiratory system?
Yes No
3)
a seizure, epilepsy, multiple sclerosis, Parkinson’s disease, muscular dystrophy, cerebral palsy, paralysis, Alzheimer’s disease or any other disorder of the brain or nervous system?
Yes No
Has a member of the medical profession ever treated you for or diagnosed you with:
1)
ulcer, hepatitis, cirrhosis, pancreatitis, ulcerative colitis, Crohn’s disease or any other disorder of the esophagus, liver, stomach or intestines?
Yes No
2)
nephritis, polycystic kidney disease or any other disorder of the bladder, kidney, urinary tract or prostate?
Yes No
3)
arthritis, gout, back trouble, or any disease or disorder of the joints, muscles or bones?
Yes No
4)
lupus, rheumatoid arthritis, chronic fatigue syndrome, fibromyalgia, or any other disease or disorder of the autoimmune system?
Yes No
Have you ever used:
1)
cocaine, crack, marijuana, heroin, Ecstasy, PCP, LSD, methamphetamine, any other hallucinogenic drug or controlled substance?
Yes No
2)
amphetamines, barbiturates, sedatives, opiates or methadone, or controlled substance except as prescribed by a physician?
Yes No
3)
Have you had or been advised to have treatment or counseling for alcohol or drug use or been asked to reduce or eliminate their usage?
Yes No
Other than what has already been disclosed, within the past 5 years, have you:
1)
requested or received disability or compensation benefits?
Yes No
2)
been a patient in a hospital or other medical facility, other than for normal childbirth?
Yes No
3)
had any other disease, disorder or condition?
Yes No
4)
been advised to have surgery, medical tests or diagnostic procedures (other than for HIV)?
Yes No
5)
are you currently receiving medical treatment that has not already been disclosed?
Yes No
6)
are you currently taking any prescription medications or herbal supplements?
Yes No
Step 4: Personal Information
Step 4: Personal Information
Step 4: Personal Information

General Information

1)
In the past five years, have you used tobacco or any other nicotine products such as cigarettes, cigars, pipe, chewing tobacco, snuff, nicotine gum, e-cigarettes, or nicotine patch?
Yes No
2)
In the past five years, have you had your driver's license denied, suspended, or revoked?
Yes No
3)
In the past five years, have you been convicted of or pled guilty to driving under the influence of alcohol and/or drugs?
Yes No
4)
In the past five years, have you been convicted of or pled guilty to any moving violations?
Yes No
5)
In the past 10 years, have you been arrested, convicted, or imprisoned for any crime and/or are you currently awaiting trial for any crime?
Yes No
6)
Will you live or travel outside the United States within the next 12 months?
Yes No

Avocation

In the past five years,
1)
have you participated in motor vehicle racing, or do you intend to?
Yes No
2)
have you participated in SCUBA diving, or do you intend to?
Yes No
3)
have you participated in mountain climbing, or do you intend to?
Yes No
4)
have you participated in skydiving, or do you intend to?
Yes No
5)
have you participated in extreme sports such as BASE jumping, bungee jumping or cave exploration, or do you intend to?
Yes No
Step 5: Aviation Information
Step 5: Aviation Information
Step 5: Aviation Information
In the past 5 years, have you flown as a pilot, student pilot or crew member or do you intend to become a pilot? (if no, you may skip the rest of this section and submit the form)
Yes No
Certificate Held
Student
Recreational
Private
Commercial
ATP
Ratings
Instrument
Multi-Engine
Instructor
Other (describe in comments below)
Medical Class
First
Second
Third
Date of last medical
Date of last flight as a pilot
What year did you become a pilot?

Estimated Flight Hours

 
Total Time
Last 12 months
Est. next 12 months
All Aircraft
Total Time
Last Year
Est. Next Year
General Aviation Aircraft
Total Time
Last Year
Est. Next Year
Scheduled Arline (Part 135/121)
Total Time
Last Year
Est. Next Year
Student
Total Time
Last Year
Est. Next Year
Military (describe in comments below)
Total Time
Last Year
Est. Next Year
Instrument (Actual & Simulated)
Total Time
Last Year
Est. Next Year
Have you ever been penalized for a violation of Federal Aviation Regulations? (if yes, describe in the comments below)
Yes No
Have you ever had an aviation accident or incident? (if yes, describe in the comments below)
Yes No
Are you flying under a waiver? (if yes, describe in the comments below)
Yes No
List all of the aircraft you own, have flown in the past 3 years, or intend to fly:
In the past 3 years, have you done:
Instruction of Students
Yes No
Agricultural Flying
Yes No
Aerobatic Flying
Yes No
Experimental Aircraft
Yes No
Ultralight Flying
Yes No
Test Flying (For Hire)
Yes No
If you answered yes to any of the above questions please give us a brief explanation: