Pilot Life Insurance | Intermountain Business Insurance LLC | South Jordan, Utah

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Pilot Life Insurance

Section 1

Pilot Certificate:

Student

Sport

Private

Commercial

ATP

Ratings:

CFI

IFR

Glider

Helicopter

Multi-Engine

Seaplane

Total lifetime flight hours:

Last 12 Months Total Hours

Last 12 Months Total Hours

Pleasure:

Business Travel:

For Hire:

Next 12 Months Total Hours

Next 12 Months Total Hours

Pleasure:

Business Travel:

For Hire:

Have you flown or do you plan to fly: (check all that apply)

Aerobatic Aircraft

Air Ambulance

Agriculture Aircraft

Employer Owned Aircraft

No Primary Instruction but other CFI work

Other Commercial Flying for Hire

Primary Instruction of Students

Please describe the type of flying / aircraft and the annual hours of each item checked above.

Have you flown or do you intend to fly outside the United States?

Yes

No

Do you fly experimental or Ultra-light Aircraft?

Yes

No

Section 2

Personal Information

Date of Birth:

Weight:

Height:

Height:

Feet:

Inches:

Sex:

Male

Female

Do you take any prescription medications?

Yes

No

Have you ever had a health condition such as cancer, cardiovascular Disease, diabetes, or any other major surgeries?

Yes

No

Ever used tobacco and/or nicotine products in any form?

Yes

No

Section 3

Family History

Any cancer or heart disease in either parent on or before age 60?

Yes

No

Mother

Mother

Age if Living

Age at Death

Father

Father

Age if Living

Age at Death

Sibling

Sibling

Age if Living

Age at Death

Sibling

Sibling

Age if Living

Age at Death

Section 4

Policy Information

Policy Amount Requested:

Term Requested:

10 Year Term

15 Year Term

20 Year Term

30 Year Term

Universal or Whole Life

Return of Premium

Additional Remarks or Quote Requests:

How did you hear about us?

Section 5

Contact Information

First Name:

Last Name:

Street Address:

Zip Code:

Email Address:

Cell Phone:

Other Phone:

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Contact

1124 W S Jordan Pkwy STE B, South Jordan, Utah 84095

Business Hours

Mon - Fri: 9:00 am - 5:00 pm
Sat - Sun: Closed

© 2026

Intermountain Business Insurance LLC

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