Kemco Insurance Agency



Specializing in Life Insurance for Pilots


You should not pay extra for your Life Insurance just because you are a Pilot.


Contact Information
Office:
1-239-403-8999
Fax:
1-239-263-9160


Submit Information for Quote


Name: State:
Type of Life Insurance: Face Amount of Life Insurance:
Height:         Weight:     Sex: Date of Birth: Month/Day/Year
       
E-mail: Phone:


Type of Airman Certificate(s) Held:

None
Airline Transport
Commercial
ATC Specialist
Flight Engineer
Flight Navigator
Flight Instructor
Private
Student
Recreational
Other


Estimated Pilot Time (Civilian Only).

Total: Hrs.
Past Year: Hrs.
Next Year: Hrs.


Have You Used Any Medication In The Last Year?

If Yes, give:
Name
Purpose
Dosage
Frequency
Yes
1st Med.
Yes
2nd Med.
Yes
3rd Med.
Yes
4th Med.
No
If medication has
not been taken in the
last year then check the
"No".
If "Yes" is checked,
for a medication that has
being taken in the last year.
Please indicate with a
"Yes" or "No"
if the medication is being
taken at the present time.

1st Med.

2nd Med.

3rd Med.

4th Med.

 Yes No

Yes No

Yes No

Yes No


Have You Used Tobacco Products In The Last 3 Years?

Yes   No


Medical History and/or Administrative Action History

Answer "Yes" for every condition you have ever had in your life.

Yes
Condition
  1. Yes Asthma of lung disease
  2. Yes Heart or vascular troubles
  3. Yes High or low blood pressure
  4. Yes Cancer
  5. Yes Diabetes
  6. Yes Neurological disorders; epilepsy, seizures, strokes, paralysis, etc.
  7. Yes Mental disorders of any sort; depression, anxiety, etc.
  8. Yes Substance dependence of failed a drug test ever; or substance
abuse or use of illegal substance in the last 3 years.
  9. Yes Alcohol dependence or abuse
10. Yes Rejection for life or health insurance
11. Yes; Admission to hospital
12. Yes Other illness, disability, or surgery
13. Yes History of any conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug.
14. Yes History of nontraffic conviction(s) (misdemeanors or felonies).


               

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