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Pilot Disability Insurance Quote Request

General Information

Section 1: Pilot Information
First Name:
Last Name:
Street Address:
City:
State:
Zip Code:
Work Phone: Home Phone:
Email Address: Fax Number:
   
Pilot Certificate: Student Sport Private Commercial ATP
*If you are not a pilot, skip to section 2
   
Ratings: CFI IFR Glider Helicopter Multi-Engine Seaplane
Medical Class: I II III
Have you ever had your FAA medical certifate denied or are there any medical restrictions on your medical?
  Yes
  No
Total lifetime flight hours:
Hours flown in the last 12 months for:
  Pleasure:
Business Travel:
For Hire:
Hours you anticipate to fly in the next 12 months for:
  Pleasure:
Business Travel:
For Hire:
Have you flown or do you plan to fly: (check all that apply) Aerobatic Aircraft
Air Ambulance
Agriculture Aircraft
Employer Owned Aircraft
No Primary Instruction but other CFI work
Other Commercial Flying for Hire
Primary Instruction of Students
Have you flown or do you intend to fly outside the United States?
  Yes
  No
Do you fly experimental or Ultra-light Aircraft?
  Yes
  No
   

Section 2:
Date of Birth:
Height: Feet Inches
Weight:
Sex: Male
  Female
Do you take any prescription medications?
  Yes
  No
Have you ever had a health condition such as cancer, cardiovascular disease, diabetes, or any major surgeries?
  Yes
  No
Any history of disability, back problems, chronic conditions, or any other medical issues that could effect the underwriting for a disability insurance policy?
  Yes
  No
Ever used tobacco and/or nicotine products in any form?
  Yes
  No
   

Section 3:
Name of Employer:
Occupation:
Annual Salary from Flying Occupation:
Annual Salary from non-flying occupation:
Monthly benefit amount requested (65% of you monthly pay is maximum benefit allowed):
Elimination period: 30 60 90 180 365 Days
Benefit period: 12 24 36 48 60 months
Any existing Disability Insurance in force?
  Yes
  No
Will you replacing an existing Disability Insurance policy?
  Yes
  No