Aircrew Loss of Licence Insurance

I have read and understood the Duty of Disclosure and Privacy Notice and I confirm I will comply with the Duty of Disclosure when answering questions.

Insured Name

Address?

Email

Contact Number?

Permanent Resident?

Yes

No

Birth Date?

Height (cm)

Weight (kg)

Salary?

Licence Number

Gender?

Male

Female

What make/models of aircraft do you regularly fly?

What types of aircraft do you fly?

Fixedwing

Rotorwing

Are you a member of a pilot union/association?

Yes

No

Please estimate the number of hours flying in the next 12 months associated with the following activities:

Private Pleasure/Business:

Commercial/Charter:

Instruction: (excluding ab initio)

Ab initio instruction:

Mustering: (including baiting, shooting and feral animal control)

Aerial application: (spraying and seeding)

Slung/lifting: (including fire-fighting and powerline stringing)

Aerobatics:

Offshore Work: (including marine pilot transfer)

Other:

Have you in the last 10 years suffered from any conditions which necessitated hospital attendance, or admission, or diagnosis, or treatment?

Yes

No

Do you currently Smoke?

Yes

No

Have you in the last 10 years receieved treatment or advice from a registered medical practitioner (including but not limited to a doctor, chiropractor, physiotherapist, psychiatrist or naturopath) in relation to:

Aircrew Loss of Licence Insurance

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