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Forms

Pilots Life Quote Request Form
For a quote on pilots life insurance, just fill out the form below and hit the PRINT button and fax it to our office (615.435.8783). Or you may also hit the submit button and a representative will contact you. If you need additional assistance, please call us at 1.800.999.1109. *Required Fields

Contact Information:
*Name:	Address:

City:	State:

Zip:


Date of Birth:	*Email Address:

*Phone:	Fax:


Height:	Weight:

Gender:	Smoker?
Male Female	Yes No
	If Yes to Smoking (kind and amount):


Pilot Information:
1. Proposed Insured:
(a.) In the past 3 years have you been a pilot or received flying instructions? Yes No
(b.) Certificate Held: Student \| Recreational \| Private Commercial \| ATP \| IFR \| VFR
(c.) Additional Ratings: Instrument \| Multi-Engine \| Instructor Other (describe in Section 8)
(d.) Medical Class: First \| Second \| Third \| Date of Last Medical
(e.) Date of last flight as a Pilot
(f.) Type of Aircraft Qualified to Fly: Fixed Wing Rotary Wing

2. Estimated Flight Hours
All Aircraft Total Time: Last 12 Mo. Est. Next 12 Mo. General Aviation Aircraft Total Time: Last 12 Mo. Est. Next 12 Mo. Scheduled Airline (135/121) Total Time: Last 12 Mo. Est. Next 12 Mo. Student Total Time: Last 12 Mo. Est. Next 12 Mo. Military Total Time: Last 12 Mo. Est. Next 12 Mo. Pleasure/Recreational Total Time: Last 12 Mo. Est. Next 12 Mo.

3. Have you ever been penalized for a violation of Federal Aviation Regulations? Yes No

4. Have you ever had an aviation accident or incident? Yes No

5. Are you flying under a waiver? Yes No

6. List all aircraft that you own, have flown in the past 3 years, or intend to fly:

7. In the past 3 years have you done: (a.) Instruction of Students Yes No (b.) Aerobatic Flying Yes No (c.) Ultralight Flying Yes No (d.) Agricultural Flying Yes No (e.) Experimental Aircraft Yes No (f.) Test Flying (For Hire) Yes No (if "Yes" to (f.) Describe type aircraft and hours flown in Section 8)

8. Comments

9. Policy Length: 10yr. 15yr. 20yr. 25yr. 30yr.

10. Policy Amount:

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