Racing 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

Racing Questionnaire

Does the proposed insured hold a racing competition license?(Required)

Yes

How many years has the proposed insured been active in motor sports?

Type of vehicle

Type of race

Number of races in the past 12 months

Number of races in the 2 years prior

Number of races anticipated in the next 12 months

Type of track or course

Location of track or course

Does the proposed insured travel to other localities to race?

Yes

Horsepower and/or engine displacement

Formula or production

Maximum speed attained (mph)

Does the proposed insured race professionally or for cash prizes?

Yes

Does the proposed insured belong to any sanctioned group?

Yes

If yes, provide details

Has the proposed insured ever engaged in stunt driving?

Yes

If no, does the proposed insured ever intend to?

Yes

Not applicable

Racing history

Include midget, sports car, stock car, modified, championship, drag, go-cart, motorcycle, motorboat, hydroplane and similar. Give type of vehicle, type of event, track or course and location, and number and miles for the past 12 months, prior 1 to 2 years, and estimated next 12 months.

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.

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