Banner Life Insurance Company Aviation Questionnaire ...
Banner Life Insurance Company 3275 Bennett Creek Avenue Frederick, Maryland 21704 (800) 638-8428
Aviation Questionnaire Supplement to Application
Supplement to application for life insurance on the life of _____________________________________________________
Yes No 1. Has flying activity as a pilot or crew member ended? If Yes, date of last flight___________________
Expiration date of license______________________
Activity as a pilot:
2. Pilot license number __________________________ Type, grade or class_____________________
Date issued _____________ Date last renewed _____________ Expiration date_______________
Describe medical or other license restrictions_____________________________________________
3. Total hours solo experience___________________________________________________________
4. Date of last flight____________________________
pilot student pilot
5. Over what areas are flights made?______________________________________________________
6. Have you ever been grounded, fined, reprimanded, or had your license revoked for aviation violations?
If Yes, explain______________________________________________________________________
7. Do you own an aircraft? If yes, make ________________ model _________________ Home built?_
8. Have you participated, or do you plan to participate in air shows?
If Yes, when? _______________________ where?_________________________________________
9. Do you have and maintain instrument flight rating (IFR)?
Military-related flying:
10. Are you, or have you served as, a member of the
Army
Navy
Marines
Coast Guard National Guard
Active Reserve
Pilot
Crew member
Date of last flight in military aircraft?_____________________________________________________
Business-related flying as a paid pilot or crew member or personal flying:
11. Type
Hours Past Hours Past Pilot Crew 12 Mo. 12-24 Mo.
Private flying, pleasure
Private flying, business
Scheduled airline
Non-scheduled airline
Company-owned plane
Instructional
Forestry, traffic control, fish and game
Inspection - pipe, power, etc.
Experimental, testing
Charter, sight-seeing, air taxi
Crop treatment
Helicopter
Photography
Stunting, racing
Glider, sailplane, ultralight
Skydiving, parachuting
Military aircraft
Hours Est. Next 12 Mo.
Type of aircraft
I hereby declare that the above statements are complete and true to the best of my knowledge and belief, and I agree that they shall form part of my application for insurance.
Signature of Proposed Insured______________________________ Witness_____________________________________ Date___________________________________________________
LU-1253 (5/05)
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