Name
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First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
Gender
*
Current Health Status
*
Please share any current health concerns
Tobacco Use
If you have quit using tobacco products, please share the date that you stopped using
Are you a current AAC member?
*
How much life insurance coverage are you looking for (we can quote face amounts as low as $10,000 and as high as $10,000,000)?
*
Desired length of coverage?
*
How long have you been climbing?
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Date of your last climb?
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Total number of climbs in the past 24 months?
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Do you ever climb solo or free (without the use of climbing aids)? If yes, please provide details below
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Travel and climbing plans for the next 24 months (only list trips and climbs that are actually scheduled and/or booked)?
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Travel and climbing experience in the past 24 months (if applicable, please include the highest YDS grade/numberical difficulty rating in the last 24 months)?
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Type(s) of climbing?
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click all that apply
Please provide details to the types of climbing you engage in
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Any climbs in the past 24 months above 13,000 feet (4,000 meters)? If yes, provide details including total number of climbs, heights attained and safety equipment used. Please also include the country/region and the name of the peak(s) and route(s) and, if applicable, include the YDS grade/numerical difficulty rating (should correspond with your answers above)
*
If applicable, please provide details to the question above
Please check any additional activities you have done in the past 24 months or intend to do in the next 24 months
*
please check all that apply
If applicable, please provide details to the question above
Interested in other products?
Please click all that apply
Thank you for your submission. A representative will be in touch as quickly as possible. If you need to speak to us immediately, please call 1-888-600-0085.
All the best,The Nicholas Hill Team
