Pre-Qualification Form

Secure Information
This information is confidential and protected over a secured server.
We will use this information only to determine your insurability, and if you wish to apply, complete your formal application for insurance. If there are any questions that you are not sure of or are not comfortable answering just skip them and we will obtain it from you later.

This is a pre-qualification form and does not obligate you to accept any coverage.
All policies are issued with a 20-day free look period from the time you receive your policy.
If you have any questions, please call our office at 1-800-380-8376.

Pilot Insurance Center

Pre-Qualification Form for Life Insurance

Five Quick and Easy Steps to Prequalify

1Your Information

2Policy Type

3Medical History

4Personal Information

5Aviation Information

First Name

Last Name

Gender

Date of Birth

MM slash DD slash YYYY

State of Birth (Country if not U.S.)

Resident Address

Address

Address Line 2

City

State

Zip

Email Address

Home Phone

Work Phone

Cell Phone

Is the Proposed Insured a permanent, legal US Resident?

Yes

Occupation

Employer

Business Address

Address

Address Line 2

City

State

Zip

Amount of Insurance

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Amount of Insurance

Guarantee Period

10 Years

15 Years

20 Years

30 Years

Permanent

Purpose of Insurance is

Personal

Business

Executive Benefit

Estate Planning

Do you currently have any life insurance?

Yes

Will this policy replace any life insurance?

Yes

Primary Beneficiary

Relationship

Contingent Beneficiary

Relationship

In order to determine your insurability, we need to ask you some medical questions. All this information is privileged and will be protected under applicable HIPPA non-disclosure laws.

Weight

Height

Height Inches

Family History

Father

Age if Living

Age at Death

Mother

Age if Living

Age at Death

Have any immediate family members (mother, father, brother, sister) been diagnosed with or died from coronary artery disease, cerebrovascular disease, diabetes or cancer before age 70?

Yes

Comments

Has a member of the medical profession ever treated you for or diagnosed you with:

1) high blood pressure, chest pain, a heart attack, coronary artery disease, a heart valve disorder, a heart murmur, an irregular heartbeat, cerebrovascular disease, a stroke, circulatory disease, an aneurysm or any disease of the heart or blood vessels?

Yes

2) anemia or other abnormality of the blood (other than HIV)?

Yes

3) a polyp, cyst, tumor, cancer, leukemia, melanoma, lymphoma or Hodgkin’s disease?

Yes

4) diabetes, high blood sugar, glucose intolerance or other endocrine disorder?

Yes

5) anxiety, depression, or any other mental or psychiatric illness?

Yes

Comments

Has a member of the medical profession ever treated you for or diagnosed you with:

1) an infection caused by the Human Immunodeficiency Virus (HIV) (Not applicable in CA. In WI: AIDS virus, HIV antibody testing is limited to FDA-licensed enzyme immunoassay and confirmatory HIV antibody tests. Any test performed at an anonymous counseling and testing site or home testing is confidential and need not be revealed on this application.), Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or any other sexually transmitted disease?

Yes

2) asthma, emphysema, cystic fibrosis, sleep apnea, sarcoidosis, tuberculosis or any other disorder of the lungs or respiratory system?

Yes

3) a seizure, epilepsy, multiple sclerosis, Parkinson’s disease, muscular dystrophy, cerebral palsy, paralysis, Alzheimer’s disease or any other disorder of the brain or nervous system?

Yes

Comments

Has a member of the medical profession ever treated you for or diagnosed you with:

1) ulcer, hepatitis, cirrhosis, pancreatitis, ulcerative colitis, Crohn’s disease or any other disorder of the esophagus, liver, stomach or intestines?

Yes

2) nephritis, polycystic kidney disease or any other disorder of the bladder, kidney, urinary tract or prostate?

Yes

3) arthritis, gout, back trouble, or any disease or disorder of the joints, muscles or bones?

Yes

4) lupus, rheumatoid arthritis, chronic fatigue syndrome, fibromyalgia, or any other disease or disorder of the autoimmune system?

Yes

Comments

Have you ever used:

1) cocaine, crack, marijuana, heroin, Ecstasy, PCP, LSD, methamphetamine, any other hallucinogenic drug or controlled substance?

Yes

2) amphetamines, barbiturates, sedatives, opiates or methadone, or controlled substance except as prescribed by a physician?

Yes

3) Have you had or been advised to have treatment or counseling for alcohol or drug use or been asked to reduce or eliminate their usage?

Yes

Comments

Other than what has already been disclosed, within the past 5 years, have you:

1) requested or received disability or compensation benefits?

Yes

2) been a patient in a hospital or other medical facility, other than for normal childbirth?

Yes

3) had any other disease, disorder or condition?

Yes

4) been advised to have surgery, medical tests or diagnostic procedures (other than for HIV)?

Yes

5) are you currently receiving medical treatment that has not already been disclosed?

Yes

6) are you currently taking any prescription medications or herbal supplements?

Yes

Please list prescription medications or herbal supplements if known

Medication

Dosage

For how long?

Medication

Dosage

For how long?

Medication

Dosage

For how long?

Medication

Dosage

For how long?

Medication

Dosage

For how long?

Comments

General Information

1) In the past five years, have you used tobacco or any other nicotine products such as cigarettes, cigars, pipe, chewing tobacco, snuff, nicotine gum, e-cigarettes, or nicotine patch?

2) In the past five years, have you had your driver's license denied, suspended, or revoked?

Yes

3) In the past five years, have you been convicted of or pled guilty to driving under the influence of alcohol and/or drugs?

Yes

4) In the past five years, have you been convicted of or pled guilty to any moving violations?

Yes

5) In the past 10 years, have you been arrested, convicted, or imprisoned for any crime and/or are you currently awaiting trial for any crime?

Yes

6) Will you live or travel outside the United States within the next 12 months?

Yes

Comments

Avocation

In the past five years,

1) have you participated in motor vehicle racing, or do you intend to?

Yes

2) have you participated in SCUBA diving, or do you intend to?

Yes

3) have you participated in mountain climbing, or do you intend to?

Yes

4) have you participated in skydiving, or do you intend to?

Yes

5) have you participated in extreme sports such as BASE jumping, bungee jumping or cave exploration, or do you intend to?

Yes

Comments

In the past 5 years, have you flown as a pilot, student pilot or crew member or do you intend to become a pilot? (if no, you may skip the rest of this section and submit the form)

Yes

Certificate Held

Student

Recreational

Private

Commercial

ATP

Ratings

Instrument

Multi-Engine

Instructor

Other

Medical Class

First

Second

Third

Basic Med

Date of last medical

MM slash DD slash YYYY

Date of last flight as a pilot

MM slash DD slash YYYY

What year did you become a pilot?

MM slash DD slash YYYY

Estimated Flight Hours

All Aircraft

Total Time

Last 12 months

Est. next 12 months

General Aviation Aircraft

Total Time

Last 12 months

Est. next 12 months

Part 135, 121, or 91 for hire

Total Time

Last 12 months

Est. next 12 months

Student

Total Time

Last 12 months

Est. next 12 months

Military (describe in comments below)

Total Time

Last 12 months

Est. next 12 months

Instrument (Actual & Simulated)

Total Time

Last 12 months

Est. next 12 months

List all aircraft you own, have flown in the past 2 years, or intend to fly:

Have you ever been penalized for a violation of Federal Aviation Regulations? (if yes, describe in the comments below)

Yes

Have you ever had an aviation accident or incident? (if yes, describe in the comments below)

Yes

Are you flying under a waiver? (if yes, describe in the comments below)

Yes

In the past 3 years, have you done:

Instruction of Students

Yes

Agricultural Flying

Yes

Aerobatic Flying

Yes

Experimental Aircraft

Yes

Ultralight Flying

Yes

Test Flying (For Hire)

Yes

If you answered yes to any of the above questions please give us a brief explanation:

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Representative

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