Obtain a tentative offer for a case involving a Pilot
by completing the form below:

1.*Agent Name :
*Address :
*City :
*State :
*Zip :
*Agent E-Mail:
Agent Phone :
2. Applicant's Name:
Date Of Birth:
Sex:	Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product:	Term Universal Whole Life
	Second to Die Variable
Have you ever used tobacco or nicotine products?	Yes No If yes, what type of product did you use? (Select all that apply) Cigarettes  Cigar  Pipe  Other
3. Do you have an Instrument Flight Rating?	Yes No
4. What level of license/certificate do you hold?
5. Is your FAA medical certificate current?	Yes No
6. How many total hours have you flown?
7. What is the purpose of your flying?
How many hours did you fly last year?
How many planned for next year?
What type(s) of aircraft do you fly?
Date of last flight:
7. Additional Comments?