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Insurance Specialist?
Why use a Pilot Life
Insurance Specialist?
Our Approach Is Different
Our Promise
Quality Coverage
Preferred Life Insurance
Rates for Pilots
Preferred Life Insurance
Rates for Pilots
Life Insurance 101
Life Insurance 101
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Why You Need Life Insurance
Less Than Perfect Health
FAQ
Types of Pilot
Life Insurance
Types of Pilot Life Insurance
Life Insurance for Commercial Pilots
Life Insurance for Private Pilots
Insurance for Agricultural Pilots
Life Insurance for Student Pilots
Life Insurance for CFI's
Life Insurance for ATP/ Corporate Pilots
Disability for Pilots
(Loss of Medical)
Disability for Pilots
(Loss of Medical)
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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
If yes, explain.
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
Please describe the type of flying / aircraft and the annual hours of each item checked above.
Have you flown or do you intend to fly outside the United States?
Yes
No
If yes, explain.
Do you fly experimental or Ultra-light Aircraft?
Yes
No
If yes, explain.
Section 2
:
Date of Birth:
Height:
Feet
Inches
Weight:
Sex:
Male
Female
Do you take any prescription medications?
Yes
No
If yes, explain.
Have you ever had a health condition such as cancer, cardiovascular disease, diabetes, or any major surgeries?
Yes
No
If yes, explain.
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
If yes, explain.
Ever used tobacco and/or nicotine products in any form?
Yes
No
Type of Product:
Amount Used:
Date Last Used:
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
If yes, explain.
Will you replacing an existing Disability Insurance policy?
Yes
No
If yes, explain.