NAME OF OWNER

ADDRESS

PHONE NUMBER

FAX NUMBER

E-MAIL ADDRESS

OPERATOR: (if different from above)

FINANCIAL INTERESTED PARTY (if any)

PERIOD 12 months from (Please indicate current expiry date)

AIRCRAFT TYPE/MAKE

REG'N

YEAR

AGREED VALUE

PAX SEATS

LIABILITIES

Combined Single Limit Required $

USES

YES/NO

HOURS PA

USES

YES/NO

HOURS PA

Private/Business Pleasure

Aerobatics

Rental for Private/Business

Aerial Agriculture

Survey/Photography

- Topdressing

Charter, Air Transport

- Spraying

Ab-initio Pilot Training

Towing

Advance Instruction

Parachuting

Corporate Use

Total Estimated Hours

PILOTS – Please provide details as to pilots names, age, qualifications, total experience (years/hours), Total F/W hours, hours on make/model of aircraft, (turbine hours if applicable), experience on specific flying uses; ie Agricultural, Parachuting, etc. Any other information that may qualify the risk in the eyes of the insurer

NAME

AGE

LICENCE

FIXED WING TT

TAILWHEEL TT
(IfApplicable)

ON TYPE TT

CLAIMS/ACCIDENTS

OPEN PILOT WARRANTY    (if required please indicate)

ACCIDENTS/CLAIMS – last 5 years    (please give date, brief details of all losses applicable to pilots and operation)

SIGNED

TITLE

NAME

DATE