PROPOSAL FORM FOR

LOSS OF LICENSE INSURANCE

IMPORTANT ADVICE TO ALL PROPSERS

ALL SECTIONS OF THE PROPOSAL FORM MUST BE FULLY COMPLETED , EVEN IF IT IS FOR RENEWAL OF , OR FOR AN ADDITIONAL AMOUNT TO , AN EXISTING INSURANCE . ALL DETAILS OF YOUR MEDICAL HISTORY MUST BE DECLARED AND SHOULD NOT BE OMITTED BECAUSE YOU HAVE BEEN DECLARED FIT OR TOLD THAT RESULTS OF MEDICAL INVESTIGATIONS HAVE BEEN SATISFACTORY , OR BECAUSE YOU THINK , OR HAVE BEEN ADVISED , THAT THEY ARE IRRELEVANT OR IMMETARIAL . FAILURE TO DISCLOSE MATERIAL INFORMATION MAY INVALIDATE THE POLICY

PERSONAL INFORMATION

SURNAME :-………………………… FIRST NAME :……………………………………………….

ADDRESS:-……………………………………………. DATE OF BIRTH:-…………………………

HEIGHT :-………………………………… WIEGHT :………………………………………………..

FLIGHT CATEGORY :-…………………………………………………………………………………

1. EMPLOYER …………………………………………………………………………………………

2. ANNUAL SALARY ………………………………………………………………………………...

3.SUM TO BE INSURED :- …………………………………………………………………………….

4.INCEPTION DATE :- ………………………………………………………………………………..

FLYING DETAILS :-

5.LICENCE HELD (DETAIL TYPES , NUMBERS AND ISSUING AUTHORITIES )

6. TYPE OF FLYING ( LAST TWO YEARS AND IN FUTURE )

7. ARE YOU MEMBER OF AN AIRCREW ASSOCIATION YES / NO

8. IS THIS PROPOSAL FOR RENEWAL OR REPLACEMENT YES / NO

OR AMENDMENT OF AN EXISTING INSURANCE

9. ARE YOU ENTITLED TO BENEFIT UNDER ANY YES / NO

ACCIDENT OR ILLNESS INSURANCE ARRANGED

BY YOU OR YOUR EMPLOYER

IF YES PLEASE GIVE DETAILS

MEDICAL HISTORY

THE FOLLOWING QUESTIONS MUST BE ANSWERED ACCURATELY AND IN FULL

10. HAVE YOU HAD INVETIGATED , DIAGNOSED OR BEEN TEATED FOR : (IF YES PLEASE GIVE DATE AND FULL DETAILS)

a) any psychiatric or nervous disorder ( including migraine) YES / NO

epilepsy or any other form of convulsion or any loss of

consciousness

b) any heart , blood pressure, circulatory or respiratory YES / NO

diorder

c) any condition involving eyes , ears , nose or throat , YES / NO

alimentory tract or genito – urinary systems

d) any condition affecting the bones and/or joints(including YES / NO

spinal conditions

e) any dioredr of the blood or lymphatic system YES / NO

f) any dioredr of the skin YES / NO

g) diabtes YES / NO

11. PLEASE GIVE DATES AND FULL DETAILS OF ANY YES / NO

OTHER MEDIACL CONDITION , ILLNES OR INJURY

WHICH HAS BEEN DIAGNOSED AND FOR WHICH

YOU HAVE HAD TREATMENT (including accidents

involving injury )

12.HAVE YOU EVER GROUNDED OR HAD YOUR YES / NO

LICENCE INVALIDATED FOR MEDICAL REASONS

(If yes please give date , full details)

13.HAS ANY LIMITATION EVER BEEN ENDORSED ON YES / NO

YOUR LICENCE

14. PLEASE GIVE THE DATE OF YOUR LAST YES / NO

ELECTROCARDIGRAPHY EXAMINATION APPROVED

BY THE LICENCE ISSUING AUTHORITY,WERE YOU

ADVISED OF ANY ABNORMALITY REVEALED BY

THIS OR ANY PREVIOUS EXAMINATION

(If yes please give date , full details)

15. AFTER OR DURING A MEDICAL EXAMINATION (If yes please give date , full details)

a) have you ever required to take additional tests) YES / NO

b) have you ever been referred for specialist examination YES / NO

c) have you ever had to return for examination at less than YES / NO

the normal interview time

d) have you ever had the issue or renewal of your medical YES / NO

certificate deferred

e) have you ever been ordered to take drugs or follow YES / NO

any special diet

16. ARE YOU AWARE OF ANY DETERIRATION IN YES / NO

YOUR GENERAL HEALTH , EYESIGHT OR BLOOD

PRESSURE

(If yes please give date , full details)

17. HAS ANY INSURANCE COMPANY

(If yes please give date , full details)

a) declined or deferred a propsal from you YES / NO

b) charged or quoted more than standard rates YES / NO

c) cancelled or declined to renew your insurance YES / NO

EXEPTIONAL DANGERS

18. DO YOU WISH TO BE COVERED FOR THE FOLLOWING RISKS

(If yes please give full details of frequency and activities of participation )

a) skin diving YES / NO

b) rock climbing or mountaineering normally involving YES / NO

the use of ropes or guides

c) potholing YES / NO

d) hange-gliding or parchuting YES / NO

e) driving or riding in any king or race or competition YES / NO

f) any other occupations , sports or activities YES / NO

which are likely invlove extra risks

19. DO YOU HAVE A MILITARY FLYING LICENCE YES / NO

(if yes please give full details of license and type and frequency of flying involved)

DECLARATION

I HEREBY DECLARED THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE PARTICULARS AND ANSWERS HEREIN ARE TRUE AND CORRECT AND THAT I HAVE NOT KNOWINGLY WITH HELD ANY INFORMATION WHICH WOULD INFLUENCE THE DECESION OF THE INSURANCE COMPANY IN REGARD TO THIS PROPOSAL FORM

IT IS UNDERSTOOD AND AGREED THAT THIS PROPOSAL SHALL FORM THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED