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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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Sky Diving


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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 does sky diving, please answer the following:

 

1. Is your client an:

 

2. How often does your client jump?  

 

3. Does your client belong to a USPA affiliated club? 

 

  

 

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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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