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PROPOSAL FORM FOR LOSS OF FLYING LICENCE
INSURANCE Your attention is drawn to the declaration at the
foot of this form. It is important that all sections of this proposal form should be fully completed even if
it is for renewal of or for an amount additional to an existing insurance. You should declare all
conditions even though you have been declared fit. You should not omit to mention investigations where
you have been told that the result is satisfactory. Failure to disclose material information may
invalidate the policy. PERSONAL INFORMATION: A. Surname: ___________________________ Rank: _____________________ First names: ________________________________________________________ Address: (in full) _____________________________________________________ ___________________________________________________________________ ___________________________________ Post
Code: ______________________ Tel: (home) _________________________ (work) ___________________________ Email: _____________________________________________________________ Date of Birth: _____________________________Height: ___________________ Weight: (current) _____________________ (12 months ago) _____________ Annual Salary: (including bonuses):
______________________________________ B. (i) Employer: ____________________________________________________ (ii) Type of Duties/aircraft: (please
tick all which apply) Commercial 􀂆 Fixed Wing 􀂆 Private 􀂆 Rotor Wing 􀂆 Instruction 􀂆 C. All Current Licences Held:_____________________________________________ (please specify type, number
____________________________________________ & country of
issue).___________________________________________________ MEDICAL INFORMATION: D. Do you hold a current medical certificate?
Yes 􀂆 No 􀂆 E. Has any limitation or endorsement been imposed
on any Licence you hold or have held? Yes 􀂆 No 􀂆 If Yes, give details
____________________________________________________ F. (i) Date of last electrocardiograph taken as
required by the Licensing Authority (dd/mm/yy) 􀂆􀂆-􀂆􀂆-􀂆􀂆 (ii) Were you advised of any abnormality in or
revealed by the examination Yes 􀂆 No 􀂆 If Yes, give details
____________________________________________________ G. Have you ever been grounded or had any licence
invalidated? Yes 􀂆 No 􀂆 If Yes, give dates and details
____________________________________________ ___________________________________________________________________ H Have you ever been required: • to take additional tests at or after a medical
examination (either routine or any other) Yes ô€‚† No ô€‚† • been referred for specialist investigation
Yes ô€‚† No ô€‚† • had the issue or renewal of any medical
certificate deferred Yes ô€‚† No ô€‚† • had to return for examination at less than the
normal interval of time Yes ô€‚† No ô€‚† • been ordered to take drugs or follow any special
diet or treatment? Yes 􀂆 No 􀂆 If Yes give dates and details
____________________________________________ __________________________________________________________________ I. Have you consulted any medical practitioner or
attended hospital during the last five years other than for the purpose of obtaining or
renewing your licence? Yes 􀂆 No 􀂆 If Yes, state when and for what
reason___________________________________ ___________________________________________________________________ J. Medical History. Do you have any other medical history which you
have not already declared? If not, please state NONE. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ K. Are you aware of any deterioration in your
health or medical fitness including (but not restricted to) a reduction in hearing,
deterioration of eyesight, back/knee discomfort etc. which may affect your ability to perform
your duties? Yes 􀂆 No 􀂆 If Yes, give
details_____________________________________________________ ___________________________________________________________________ L. Have you ever smoked cigarettes, cigars or a
pipe? Yes 􀂆 No 􀂆 Have you smoked in the last 12 months? Yes 􀂆 No 􀂆 If Yes, state average daily
quantity_______________________________________ M. Have either of your parents or brothers or
sisters had diabetes, heart disease, high blood pressure or a mental or nervous disease?
Yes 􀂆 No 􀂆 If so, please give full details, including
approximate age at onset ___________________________________________________________________ N. Has any Insurance Company or Underwriter: (i) declined or deferred a Proposal from you?
Yes 􀂆 No 􀂆 (ii) charged or quoted more than standard rates
(other than occupational load)? Yes 􀂆 No 􀂆 (iii) cancelled or declined to renew your
insurance? Yes 􀂆 No 􀂆 If Yes, give details
____________________________________________________ ___________________________________________________________________ O. Access to Medical Reports (please see over for
further details): The Company may require additional medical
information therefore, if you have completed any section declaring medical
history, please complete the following: Usual Doctor or General Practitioner’s name and
contact address: Consultants name and consultants address: I do/do not wish to see the report before it is
sent to the Insurers* *delete as applicable. I have been informed of my rights under the
Access to Medical Reports Act 1988 (if applicable) and hereby consent to the
Insurers obtaining medical reports in connection with this application. BASIS OF COVER: P. Sum to be Insured: Q. Please state if this Proposal is: a) your first proposal to this company 􀂆 or b) for renewal of an additional amount to an
existing insurance 􀂆 (if (b) state existing Policy No. and amount
insured and Agent). ___________________________________________________________________ ___________________________________________________________________ R. Are you entitled to benefit from any other
“Loss of Licence, Permanent Health or Aircrew Disability Insurance?” Yes ô€‚† No ô€‚† If Yes, state type and the
amounts insured _________________________________ ___________________________________________________________________ DECLARATION: I hereby declare that to the best of my knowledge
and belief the answers to the foregoing questions whether in my own handwriting or not
are true and complete and that I have not withheld any information which might influence
the decision of the Insurers with regard to this proposal. I agree that this proposal and
declaration shall be the basis of the Contract between me and the Insurers if a policy is
issued. Signed:__________________________________ Dated: __________________________ The Company reserves the right to impose special
conditions or refuse to accept a proposal for insurance. ACCESS TO MEDICAL REPORTS ACT 1988 To process your application we may need to obtain
a medical report from any doctor who has attended you. You can withhold your
consent for us to obtain the report, but without it cover may be restricted.
You are responsible for any fees incurred by us in obtaining such reports. If you consent, you can see the medical report
before it is sent to us. We will inform you when we write to the doctor, and
you need to obtain your copy within the next 21 days. If after 21 days the
doctor has not heard from you, he can send his report directly to us, and you
can still request a copy any time during the following six months for which
you may be charged. If you see the report within the 21 days, the
doctor must obtain your consent before sending it to us. You can ask the
doctor to amend any part of the report which is incorrect or misleading. You
can attach a statement of your views on any part of the report where you and
the doctor are not in agreement. The doctor does not have to let you see any part
of the report which could cause serious harm to your physical or mental
health, or that of others, or would indicate the doctor’s intentions towards
you, or if information about you which has been supplied by another person,
other than a health professional, would be revealed. If the doctor withholds any part of the report
from you, he must inform you of this fact. If it is the whole report which is
affected, the doctor must not send it to us unless you consent to this. If you do not wish to see the report, the doctor
will send it to us immediately, but he must keep a record of the report for a
period of six months, and you may apply to see a copy of the report during
this time. |
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You must take all reasonable steps to mitigate any loss. If required
You will execute any documentation or do anything necessary to enable Us to
be directly involved in the recovery of the Insured Debt. |
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