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Voice Fax


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Aviation


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Please complete the underwriting information questionnaire and any other medical impairment page necessary to properly underwrite your client.

 

                                          * Mandatory Fields

 

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?      

 

If your client pilots his own aircraft, please answer the following:

 

1. Is your client a:  

 

2. Is your clients license/certificate current?  

 

3. Is your clients FAA medical certificate current?  

 

4. Total hours flown?  

 

5. What is the purpose of your client flying? 

 

            a. How many hours did your client fly last year? 

            b. How many hours planned next year?  

            c. What type of aircraft does your client fly?  

            d. Date of your clients last flight?  

            e. Does your client fly over large bodies of water?  

                If yes, please give details: 

 

  

 

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Please complete the Main Underwriting Worksheet and send it along with the this page or any other impairment page necessary to complete underwriting.



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