Racing Questionnaire

Racing Questionnaire Please answer all questions applicable to the client’s medical history. Producer Name Phone Date Client Name Date of Birth Male Female Face Amount Max Premium $ /yr. UL WL Term Survivorship Does the client currently smoke cigarettes Yes No If no, did he/she ever smoke? Never Quit (date) Does the client currently use any other tobacco products (e.g. nicotine patch, cigars, pipe, snuff, Nicorette gum, etc.) Yes No If yes, please provide details: When did he/she last use any form of tobacco: (Month) (Year) Type used last: Does the client hold a competition driver’s license from any organization Yes No If yes, list all Has the client ever attended any type of driver’s school Yes No If yes, which How long has the client participated in racing Date of last race Where Over what type of track does the client race (e.g. dirt oval, simulated road, off road, etc.) How far does the client travel to race Has the client ever competed, or do they intend to compete, outside the US Yes No If yes, where Does the client intend to enter a new class of competition Yes No If yes, provide details Has the client ever done, or intend to do, any stunt driving Yes No Is racing the client’s full-time occupation Yes No Does the client compete on a traveling circuit Yes No If yes, which In which racing categories has the client participated or plan to participate in the next two years All terrain vehicle Auto crash Dive bomber Roll over T-Bone Demolition Destruction Figure 8 Other Drag Racing Top Fuel dragster Top alcohol dragster Prostock Other Kart Formula kart experimental Sprint (mph ) Enduro (mph ) Midget (mph ) Off road Desert (Baja) Other (Continued) FOR INSURANCE PROFESSIONAL USE ONLY- not intended for use in solicitation of sales to the public. For use with non-registered products only. Products and programs offered through BB&T Life Insurance Services are not approved for use in all states. 09.26.12 © 2014 BB&T Life Insurance Services Racing Questionnaire Sports car Formula Formula 1 Atlantic Continental Ford Vee 440 Other Grand touring GT-1 Trans-Am GT-2 GT-3 GT-4 GT-5 Other IMSA GT Production E F G H Other Rally Pro rallying Other Showroom stock SSGT SSA SSB SSC Other Sports racing ASR Can-Am CSR DSR Sports 2000 Sports Renault Other Sprint cars USAC sprint car Other Stock cars (NASCAR/IMSA) Nextel Cup Winston West Busch Grand National Modified division USAC Super Modified Grand American All American Challenge Late Model Charlotte/Daytona Dash Chargers ProFormance/ProStock Sedan Street Stock American Challenge Other Other Name of organization sanctioning races Local/regional organization National organization Not sanctioned Provide particulars by types of races and miles driven in competition, stating “none” where now, as provided below Last 12 Months 1-2 Years Ago Contemplated Next 12 Months Racing Maximum Maximum Category Number of Races Miles Per Race Number of Races Miles Number of Races Miles Speeds Attained Speeds Expected Do you own a competition vehicle Yes No If yes, complete the following Make and model Displacement Class Do you have access to any other competition vehicle Yes No If yes, complete the following Make and model Displacement Class Type of fuel used List any major health problems the client has (e.g. cancer, etc.). FOR INSURANCE PROFESSIONAL USE ONLY- not intended for use in solicitation of sales to the public. For use with non-registered products only. Products and programs offered through BB&T Life Insurance Services are not approved for use in all states. 09.26.12 © 2014 BB&T Life Insurance Services.

Load more