Hazardous Activities Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
Do you, have you ever, or do you expect to engage in: 1. Any sport, avocation or hobby not listed below? If not listed below, describe fully, showing frequency, length of time engaged in this activity, hazards, associations or clubs to which you belong, etc. 2. Rodeo competition? A. Type of activity?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
B. How often? C. Date of last? 3. Skin diving? A. How long have you been skin diving? B. How often? C. Date of last? D. Average depth?
Questions
E. Greatest depth? F. Maximum time under water? i. Do you use S.C.U.B.A. equipment? ii. Have you ever done underwater recovery or salvage work? When? What type? 4. Sky diving or parachute jumping? A. How long have you been sky diving? B. How often? C. Total number of jumps made? i. Do you belong to any sky divers’ association or club? (If so, what is the name?) ii. Are all jumps made under auspices of your association or club? (If not, give details.)
GBU FINANCIAL LIFE
FL20-HAZ.2
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Hazardous Activities Questionnaire(continued) 5. Racing, performance testing or stunt driving—automobile, motorcycle, motorboat?
Yes
No
i. Have you ever attended any type of driver’s or operator’s school? (If so, what is the name?)
Yes
No
ii. Do you hold a competition driver’s license from any organization? (If so, what is the name?)
Yes
No
a. Other than sanctioned events?
Yes
No
b.
Stunt driving?
Yes
No
c.
Racing professionally or for cash prizes?
Yes
No
A. How long have you been participating? B. Date of last event? C. Location of last event?
iii. Have you ever, or do you expect to, engage in:
Questions (continued)
D. Types and number of events and mileage in past twelve (12) months, past one (1) to (2) years and estimated total for next twelve (12) months? (Include midget, sports car, stock car, modified, championship, drag, go-cart, motorcycle, motorboat, hydroplane.) Type of Events
Past 12 Months Number
Miles
Past 1 – 2 Years Number
Miles
Estimate Next 12 Months Number
Miles
I declare that all statements and answers to the foregoing questions are, to the best of my knowledge and belief, complete and true. I agree (a) that they shall form a part of my application; (b) that they shall be subject to the terms of the agreement found in the application; and, (c) that they shall become part of any policy based on my application. Fraud Warning. Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of Acknowledgement claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Signature of Proposed Insured or Guardian
FL20-HAZ.2
Date
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