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Preliminary Inquiry Form

Preliminary Inquiry

Personal History – Proposed Insured

Name:

Social Security Number:

Gender: Male Female

U.S. Citizen: Yes No

Address:

City:

State:

Zip:

Work Phone:

Home Phone:

Date of Birth:

Age:

Height:

Weight:

Occupation:

Driver's License #/State:

Do you currently use:
Cigarettes Cigars Other

If yes for Cigars, frequency/quantity:

If yes for Other, provide details:

If no for cigarettes, years/months last smoked if less than 3 years:

Do you have plans to travel or reside outside the US? Yes No

If yes, provide dates and details:

Have you piloted/flown an aircraft in the past two years? Yes No

Informal Inquiry Form

Preliminary Inquiry - Personal History

Name:

Gender: Male Female

Social Security Number:

U.S. Citizen: Yes No

Address:

City:

State:

Zip:

Work Phone:

Home Phone:

Date of Birth:

Age:

Height:

Weight:

Occupation:

Driver's License #/State:

Do you currently use:
Cigarettes Cigars Other

If yes for cigars, frequency/quantity:

If yes for other, provide details:

If no for cigarettes, years/months last smoked if less than 3 years:

Do you have plans to travel or reside outside the US? Yes No

If yes, provide dates and details:

Have you piloted/flown an aircraft in the past two years? Yes No

Number of total flying hours:

Number of hours flown in the past 12 months:

Number of hours expected to fly in the next year:

Type of License:

Do you have an IFR? Yes No

In the past 5 years have you:
Been in a motor vehicle accident Been charged with a moving violation DUI Had your license revoked

If yes, provide dates and details:

Have you ever engaged or plan on engaging in:
Mountain climbing Racing Underwater diving Any hazardous sport or hobby

If yes, provide dates and details:

Email Address:

Place of Birth:

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