Loss Of License Aviation

Proposal Application for Aviation Loss of Licence or Personal Accident Insurance

To provide you with a Premium Indication, Underwriters require the following Proposal Application to be completed. Please provide complete responses to each item. All details of your medical history must be declared and should not be omitted because you have been declared fit or told results of medical investigations have been satisfactory or because you think or have been advised they are irrelevant or immaterial.

Incomplete forms cannot be processed or acknowledged

eMail*

Enter your eMail address to proceed

DISCLOSURE
Your written responses and this document and any attachments forms part of an application for insurance products or forms part of an Underwriter's file for an existing insurance policy or changes to an existing insurance policy. You must answer each question completely and accurately. Failure to do so may result in delay of policy issue or coverage, a denial or reduction of benefits or cancellation or voiding of coverage.
Submission of this electronic or digital document with your typed digital or electronic signature shall have the same legal force and effect as if you had signed the document with your handwritten original signature.

First Name*

Middle Name(s)*

Last Name (Surname)*

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Phone 1*

Phone 2

Birthdate MM/DD/YYYY*

MM/DD/YYYY

Gender*

Height & Weight questions follow. Do you prefer Inches & Pounds or Kilos & Centimetres?*

Chosse to provide information in Inches & Pounds or Metric measure

Height in INCHES or CM*

Weight in Pounds or Kilos*

Weight 12 Months Ago*

Employment*

Are you self-employed?

Employer*

If self-employed state the name of your business or Trading Name

Annual Gross Personal Salary from Aviation-related employment*

What is your Aviation-related Occupation or Employment*

Is a Licence required for your Aviation-related employment?*

Certain Aviation-related occupation(s) do not require government licencing.

Licenses Held for my Aviation-related occupation

Detail types, numbers, and issuing authorities

Do you fly as part of your Aviation-related employment?*

Type of Flying*

Last two years and in future

Are you a member of an Aircrew or Aviation-related association?*

Please provide details.

List any Non-Flying Occupation(s)*

Exceptional Dangers

To be covered for any of the following risks, please check them below and complete the questionnaire on the next page*

Skin or SCUBA diving. Rock climbing or Mountaineering normally involving the use of ropes or guides. Driving or riding in any kind of race or competition. Hang-gliding, paragliding or parachuting. Potholing or Gunkholing. Any other occupations, sports, pasttimes, or activities likely to involve extra risk. NO coverage required for the activities listed above.

Exceptional Danger coverage information

If you selected any of the additional risks on the previous page, please answer the following six questions.

List sport pastimes involved

Frequency?

Your Qualifications and Experience?

Do you participate as an individual or as a team-member?

Is participation regulated by a governing body? If so, which?

Is any element of competition involved? If so, is this supervised by the governing body?

Continue to signature Page*

Continue to Sign and submit this Insurance Proposal Application

READ CAREFULLY BEFORE SIGNING

I HEREBY AFFIRM ALL OF THE INFORMATION HEREIN IS TRUE AND CORRECT AND ALL STATEMENTS MADE IN THIS DOCUMENT HAVE BEEN ANSWERED TO THE BEST OF MY ABILITY AND ARE TRUE AND COMPLETE.
I HAVE NOT KNOWINGLY OR INTENTIONALLY CONCEALED OR MISREPRESNTED AND FACT. I HAVE READ AND I UNDERSTAND THE DISCLOSURE STATEMENT ON THIS DOCUMENT. THIS FORM WILL BECOME PART OF THE INSURANCE APPLICATION PROPOSAL.
DISCLOSURE
Your written responses and this document and any attachments forms part of an application for insurance products or forms part of an Underwriter's file for an existing insurance policy or changes to an existing insurance policy. You must answer each question completely and accurately. Failure to do so may result in delay of policy issue or coverage, a denial or reduction of benefits or cancellation or voiding of coverage.
Submission of this electronic or digital document with your typed digital or electronic signature shall have the same legal force and effect as if you had signed the document with your handwritten original signature.
By submitting your information you acknowledge we may contact you by voice, facsimile or electronics means including but not limited to the review or discussion of your information and the distribution of promotional or informative materials &/or coverage documents.

Full Name*

Your eMail address*

Affirmation required*

I HEREBY AFFIRM ALL OF THE INFORMATION HEREIN IS TRUE AND CORRECT AND ALL STATEMENTS MADE IN THIS DOCUMENT HAVE BEEN ANSWERED TO THE BEST OF MY ABILITY AND ARE TRUE AND COMPLETE. I HAVE NOT KNOWINGLY OR INTENTIONALLY CONCEALED OR MISREPRESENTED ANY FACT. I HAVE READ AND I UNDERSTAND THE DISCLOSURE STATEMENT ON THIS DOCUMENT. THIS FORM WILL BECOME PART OF THE INSURANCE APPLICATION/PROPOSAL.I further agree and acknowledge my written responses and this document and any attachments forms part of an application for insurance products or forms part of Underwriters file for an existing insurance policy or changes to an existing insurance policy. I have answered each question completely and accurately. I acknowledge and agree failure to do so may result in delay of policy issuance or coverage, a denial or reduction of benefits or cancellation or voiding of coverage. I acknowledge and agree submission of this electronic or digital document with my typed digital or electronic signature shall have the same legal force and effect as if I had signed the document with my handwritten original signature.

Save and Resume Later

Progress

Medical History

Exceptional Dangers

Exceptional Danger coverage information

READ CAREFULLY BEFORE SIGNING