| Insured Name:
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______________________________
|
| Town or City:
|
______________________________
|
| Country:
|
______________________________
|
| E-Mail Address:
|
______________________________
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| How many aircraft do you wish to insure?
|
______________________________
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| Currency you wish to pay your premium in:
|
______________________________
|
| Name of current Insurer:
|
______________________________
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| Current Premium:
|
______________________________
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| Do you own, lease or rent premises on an airfield or airport?
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YES / NO
|
| Has any insurer ever declined to insure or renew your policy?
|
YES / NO
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If "Yes" please provide details:
|
______________________________
|
Aircraft
|
| Make of aircraft:
|
______________________________
|
| Model of aircraft:
|
______________________________
|
| Aircraft registration number:
|
______________________________
|
| Aircraft serial number:
|
______________________________
|
| Maximum take off mass in kilograms:
|
______________________________
|
| Aircraft year of manufacture:
|
______________________________
|
| Aircraft Currency:
|
______________________________
|
| Aircraft Agreed Value:
|
______________________________
|
| Declared maximum number of passengers:
|
______________________________
|
| Please advise where aircraft based:
|
______________________________
|
| Is the aircraft hangared?
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YES / NO
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| Please advise estimated utilisation (hours) during the policy period:
|
________Hours
|
| Do you wish to ensure the aircraft for ground risks only?
|
YES / NO
|
| Club - including ab initio training
|
YES / NO
|
| Club - excluding ab initio training
|
YES / NO
|
| Rental
|
YES / NO
|
| Aerobatics
|
YES / NO
|
| Air Shows
|
YES / NO
|
| Commercial : (Carriage of passengers/cargo for hire)
|
YES / NO
|
| Aerial Photography
|
YES / NO
|
| Aerial Survey
|
YES / NO
|
| Industrial Aid
|
YES / NO
|
| EC785/2004 Classification:
|
Commercial / Non Commercial
|
| Do you own this aircraft outright? (please answer "No" if the
aircraft is financed in any way)
|
______________________________
|
| Name of bank/lender/lien holder:
|
______________________________
|
Address of bank/ lender/ lien holder:
|
______________________________
|
Do you wish to name the above as Loss Payee?
|
YES / NO
|
What amount is currently outstanding?
|
______________________________
|
From the 30th April 2005 EC785/2004 is effective and minimum insurance requirements
apply to all operators of aircraft flying within EEA airspace. It is your
responsibility to make sure you choose the correct insurance cover.
|
What liability limit is required for the following:
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Combined Single Limit: (covers liability to Passengers and Third Parties
arising out of the use of Aircraft and Premises Liability) each Occurrence
|
______________________________
|
Alternatively
|
Combined Single Limit: (covers liability to Third Parties only arising out of the
use of Aircraft and Premises Liability) each Occurrence
|
______________________________
|
Combined Single Limit: (covers liability to Passengers only arising out of
the use of Aircraft) each Passenger
|
______________________________
|
Pilot Details
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Will more than 5 pilots fly the aircraft?
|
YES / NO
|
What is the minimum level of pilot license?
|
______________________________
|
Maximum age:
|
______________________________
|
Minimum total flying hours:
|
______________________________
|
Minimum flying hours on make and model:
|
______________________________
|
Has any pilot who will fly the aircraft had an accident or licence violations
in the last 5 years?
|
YES / NO
|
If "Yes", please provide details:
|
______________________________
|
Do you sell food or drink to Third Parties?
|
YES / NO
|
If "Yes", what is your turnover from such sales?
|
______________________________
|
Do you provide car parking facilities for use by third parties ?
|
YES / NO
|
If "Yes", Do you display disclaimer notices in such facilities?
|
YES / NO
|
Do you use vehicles on the airside part of any airfield or airport?
|
YES / NO
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If "Yes", how many?
|
______________________________
|
Have you had any Premises Liability claims made against you in the past 5 years?
|
YES / NO
|
If "Yes", please provide full details:
|
______________________________
|
Declaration:
By pressing on the Submit button below I warrant that all facts are correct, that the aircraft has
not been modified to enhance performance and that the value thereof represents a fair market value.
No pilot who will fly the aircraft has had an accident or licence violation in the past 5 years except
as declared on the Application Form. This will provide the basis of the Contract.
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