Impaired Risk - HBW Insurance & Financial Services, Inc.

In order to get the most accurate underwriting, please be as thorough as possible. Failing to include information may completely change underwriting results.

Agent Information

Agent Name
Agent Fax

Agent Phone
Agent Email

Client Information

Client Name

Client Age

Client DOB

Client Sex

Client Height

Client Weight

Underwriting Questions Pertaining to Piloting Aircraft

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?

General Underwriting Questions

Has your client recently been rated or declined for coverage? Yes: No:

What type of insurance is desired?

	Term
	Universal
	Whole life

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:

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

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

Additional Comments :

Please press submit only once per case.

Impaired Risk Cases

Aircraft Pilot Impairment Questionnaire

Agent Information

Client Information

Underwriting Questions Pertaining to Piloting Aircraft

General Underwriting Questions

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