Propose Insured Name:
*
Preferred Contact Method:
Email
Call
Text
Phone:
*
Email:
*
Height:
*
Weight:
*
Date of Birth:
*
Sex(M/F):
*
1. Do you, or have you ever used tobacco? If “yes” please provide details.
Yes
No
Quantity
*
Frequency:
*
Form:
*
Last Used:
*
2. Do you, or in the last 5 years have you ever used marijuana? If yes, please explain frequency, reason why, and whether or not you have a prescription.
Yes
No
3. Have you seen a doctor in the last five years (Please include reason seen and when last seen)?
Yes
No
*
4. Are you taking any prescribed medications? (Please include when were you prescribed the medication, dosage and reason taken)
Yes
No
*
5. Do any immediate family members (parent and/or siblings) have a history of cancer, diabetes, or cardiovascular disease? If so, please advise detail to include when they were diagnosed with the condition, if they are still living, and if they are deceased, when they died and whether or not they died from any of these conditions.
Yes
No
*
6. Have you had any citations for DUI, reckless driving or any moving violations in the last five years? If so, please provide details.
Yes
No
*
7. Any private pilot activity in the last 3 years or planned for the future? If yes, please provide details.
Yes
No
*
8. Any participation in any hazardous avocation or sport in the last 3 years or planned for the future? If yes, please provide details.
Yes
No
*
9. Any past travel in the last 2 years or future plans to travel outside the U.S.? If yes, please provide details to include specific destination, frequency and duration of travel.
Yes
No
*
10. Are you a citizen or legal resident of the U.S.? If no, please provide details.
Yes
No
*
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