Aircraft Pilot Impairment Questionnaire

Agent Name :

Agent Phone :

Agent Fax :

Agent Email :

Client Name :

Client Age :

Client DOB :

Client Sex :

Client Height :

Client Weight :

Does your client have an Instrument Flight Rating ? Yes : No :

What level of license/certificate does your client hold ?

Is your client's FAA medical certificate current ? Yes : No :

How many total hours has your client flown ?

What is the purpose of your client's flying ?

How many hours did your client fly last year ?

How many hours does your client plan to fly next year ?

Please list the type(s) of aircraft your client flies or has flown :

What is the date of your client's last flight ?

What type of insurance is desired ?

If you selected term, what is the desired term length ?

What is the desired Face Amount ?

Please list your client's current medications and the reasons they are taking them :

Has your client used tobacco in the last 12 months ? Yes : No :

If yes, please list the type, frequency, and amount of tobacco used :

Does your client have any other major health problems ? (Ex: Cancer, diabetes, ulcers, etc. ) Yes : No :

If yes, please give a detailed description of problem(s) :

Do any of your client's relatives have a history of the impairment or any other medical conditions ? Yes : No :

If yes, please list which family member(s), give a detailed dscription of their condition(s), and list which, if any, are living or non-living :

Additional Comments :