Aviation Questionnaire

Complete what you know and submit. Anything you leave blank will not stop the submission, but the more detail you give an underwriter, the faster we can shop the case.

Download the printable PDF

Agent & Case Information

Agent Name(Required)

First Last

Phone(Required)

E-Mail(Required)

Proposed Insured

Client Name(Required)

First Last

You may enter client initials. We don't share client information with carriers on risk assessments.

Date of Birth(Required)

State(Required)

Height(Required)

Weight(Required)

Face Amount(Required)

Sex(Required)

Male

Female

Tobacco / Nicotine Use(Required)

Yes

Coverage Requested

Type of Insurance

Universal Life

Whole Life

Survivorship

Term

If term, number of years

Aviation Questionnaire

Commercial flying hours as pilot or co-pilot(Required)

For scheduled passenger airlines, employer-owned aircraft, non-scheduled or charter, military, crop dusting or aerial spraying, student instruction, exhibition or stunt flying, and other. Give next 12 months, past 12 months and prior 12 to 24 months.

Non-commercial flying hours as pilot or co-pilot

For pleasure, personal business transportation, instruction as a student, and other. Give next 12 months, past 12 months and prior 12 to 24 months.

Certificate license

Student

Private

Commercial

ATP

Does the proposed insured have an instrument flight rating?

Yes

Any other ratings?

Yes

If yes, provide details of other ratings

What class of FAA Medical Certificate does the proposed insured hold?

Date of the proposed insured's last FAA medical exam

Does the proposed insured use anything other than public airports?

Yes

Has the proposed insured flown outside of the US?

Yes

If no, does the proposed insured ever intend to?

Yes

Not applicable

Has the proposed insured flown a prototype, experimental or personally built aircraft, rotorcraft, balloon or glider?

Yes

If yes, provide details

How many total lifetime hours has the proposed insured flown?

Any additional remarks?

Is the proposed insured currently taking any medication(s)?

Yes

If yes, provide name, dosage and frequency of medication(s)

Attachments

File Upload

Drop files here or

Max. file size: 512 MB.

Attach medical records, lab slips, pathology or test reports.

CAPTCHA

Questions before you submit? Call the underwriting desk at 866.639.0443.