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22 Mill St. #410, Arlington, MA 02476,  Voice 800 700-7505 Fax 781 643-2775


lgcorsetti@doukakiscorsetti.com


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Mountain Climbing


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Please complete the underwriting information questionnaire and any other medical impairment page necessary to properly underwrite your client.

 

                                          * Mandatory Fields

 

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?      

 

If your client climbs mountains, please answer the following:

 

1. Where does your client climb?     Type?  

 

2. What is the maximum  level of technical training?  

 

3. Does your client do any ice climbing?  

 

  

 

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Please complete the Main Underwriting Worksheet and send it along with the this page or any other impairment page necessary to complete underwriting.



Main Underwriting Worksheet                  Medical and Avocation Selections Page

 

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