AIRCRAFT INSURANCE PROPOSAL FORM

Unless all material facts are disclosed, this insurance could be invalidated. Material Facts are those facts an Insurer would regard as likely to influence the acceptance and/or assessment of the Proposal. If you are in any doubt about whether facts are material, you should disclose them.

A copy of the completed Proposal Form will be supplied on request but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract.

Commencement Date of Insurance: (Which cannot be before the acceptance of the Proposal by the Insurers)

EXPIRY DATE of Insurence:

1. PROPOSER

a) Proposer’s Name

Company:

Individual:

Proposer’s Interest in the Aircraft:

c) Postal Address:

Telephone:

(Home):

(Business):

(Cell):

f) E-mail:

g) Occupation:

h) Age:

Have you or any member of your family residing with you, or directors where the Proposer is a limited company, ever been convicted of any offence other than driving offences?

Yes

If ‘YES’ to the above question please give details here

2. AIRCRAFT DETAILS

a) Manufacturer

b) Model

c) Year

Amount of Airframe Time

e) Engines

f) Engine Hours

g) Number of Crew Seats

Number of Passenger Seats

Average Passenger Load

j) Registration No.

Country of Registration

Hull and Machinery Value

m) Date of Last Annual

Where is the Aircraft kept

Where is the Aircraft maintained (location)

Name of Maintenance Company (location)

3. PILOTS

Pilot 1

a) Name

b) Age

c) Hours & Rating

1. Total flying hours

Total Turbine Engine Hours

Hours make and model

Total multi engine hours

Type of license held

Pilot 2

e) Name

f) Age

g) Hours & Rating

1. Total flying hours

Total Turbine Engine Hours

Hours make and model

Total multi engine hours

h) Type of license held

Pilot 3

i) Name

j) Age

k) Hours & Rating

1. Total flying hours

Total Turbine Engine Hours

Hours make and model

Total multi engine hours

l) Type of license held

Do Pilots attend Manufacturer approved Flight/Simulator training and if so, how often do the pilots attend?

Please state the minimum licenses/experience requirement levels for any unnamed pilots.

4. INSURANCE (please tick as appropriate)

Existing Insurance Arrangement

Yes

New Craft

Yes

a) Present Insurer

b) Period of Insurance

c) Current Premium

d) Excess

5. LIABILITY INSURANCE

Public Liability (Bodily injury & Property damage) – Limit per occurrence: BSD

Passenger Liability - Limit per person: BSD

Passenger Liability - Limit per occurrence: BSD

Crew Personal Accident – Limit per occurrence: BSD

Definitions of Uses:

Private Pleasure is defined as use for private and pleasure purposes but NOT use for any business or profession nor for hire or reward.

Business is defined as use for the purpose of the Insured’s business or profession but NOT use for hire or reward.

Commercial is defined as use for the carriage by the Insured of passengers, baggage accompanying passengers and cargo for hire or reward.

Rental is defined as rental, lease, charter or hire by the Insured to any person, company or organization for Private Pleasure and Business uses only, where the operation or the Aircraft is not under the control of the Insured. Rental for any other purposes is NOT insured under this Policy unless specifically declared to Insurers.

7. GEOGRAPHICAL OPERATING AREA OF THE AIRCRAFT

Please state Geographical Operating Area of the Aircraft:

Does the Aircraft fly to the United States of America?

Yes

If the answer is YES to Question 7b) above is it for maintenance purposes only?

Yes

If the answer is NO to Question 7c) what is the approximate percentage in overall hours the Aircraft is flying in the airspace of the United States of America?

8. PREVIOUS LOSSES OR CLAIMS

a) Have you ever had any accidents or losses whether covered by insurance or not?

Yes

If you have answered ‘YES’ to the above question please give details here

9. DECLARATION

I/we declare that the above statements made by me/us or written in answer to the questions on this form on my/our behalf by someone else are to the best of my/our knowledge and belief true and complete, and no material fact has been misrepresented, misstated or withheld. I/we agree that this proposal shall form the basis of the contract between me/us and the Insurers and will be deemed as incorporated in the Policy to be issued.

AIRCRAFT INSURANCE PROPOSAL FORM

1. PROPOSER

2. AIRCRAFT DETAILS

3. PILOTS

Pilot 1

Pilot 2

Pilot 3

4. INSURANCE (please tick as appropriate)

5. LIABILITY INSURANCE

6. USE OF AIRCRAFT (please tick as appropriate)

Definitions of Uses:

7. GEOGRAPHICAL OPERATING AREA OF THE AIRCRAFT

8. PREVIOUS LOSSES OR CLAIMS

9. DECLARATION

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