Pilots Insurance

TO OUR MOST VALUED CLIENTS

All sections of this proposal form must be completed in full in English.

You must take care in answering all the following questions which are relevant to insurers in providing this insurance and setting the terms and premium. Please contact us if you do not understand the question or the nature of the information required. Failure to provide information or the provision of incomplete or inaccurate information may result in the loss of cover or other remedies.

You must tell insurers as soon as practicably possible about any changes to the information you have provided which happens before or during any period of insurance. We will tell you if such change affects your insurance and if so, whether the change will result in revised terms and/or premium being applied to your policy. If you do not inform insurers about a change, it may affect any claim you make or could result in your insurance being invalid.

    PERSONAL DETAILS















    Day
    Month
    Year


    MaleFemale



    Day
    Month
    Year




    NoYes



    NoYes



    NoYes



    NoYes



    NoYes



    Fixed WingRotor Wing (on shore)Rotor Wing (off shore)

    Type

    Number

    County Issued

    Limitation


    NoYes

    Type 2

    Number 2

    County Issued 2

    Limitation 2

    Type 3

    Number 3

    County Issued 3

    Limitation 3

    Type 4

    Number 4

    County Issued 4

    Limitation 4

    Type 5

    Number 5

    County Issued 5

    Limitation 5

    BASIS OF COVER


    NoYes





    NoYes





    Day
    Month
    Year


    NoYes





    Day
    Month
    Year


    NoYes





    Day
    Month
    Year





    Day
    Month
    Year





    Day
    Month
    Year


    NoYes



    NoYes



    Your FirstAn Additional


    MEDICAL INFORMATION

    NoYes


    NoYes


    Day
    Month
    Year

    NoYes


    Day
    Month
    Year

    NoYes



    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes
    NoYes

    NoYes

    NoYes
    NoYes

    NoYes
    NoYes

    NoYes


    NoYes


    NoYes


    NoYes


    NoYes


    NoYes


    NoYes


    NoYes


    NoYes


    The Insurer may require additional medical information. If you have completed any section declaring medical history, please complete the following.




    PRIVACY & COOKIES

    Please read this document Millstream Privacy and Cookies.


    DECLARATION

    I/we declare that the information disclosed in this proposal, is to the best of my/our knowledge and belief both accurate and complete. I/we have taken care not to make any misrepresentation in the disclosure of this information and understand that all information provided is relevant to the acceptance and assessment of this insurance, the terms on which it is accepted and the premium charged.

    I/we also consent to any information the Insurer may have about me/us being processed by them for the purposes of providing insurance and claims handling which may necessitate them providing such information to third parties.

    You and insurers are entitled to choose the law that will govern this contract of insurance. Insurers propose English law and this will apply unless otherwise agreed.

    Signing this proposal does not bind you to enter into this insurance.

    No cover is in force until this proposal is accepted by the insurers and the premium is paid. The insurers reserve the right to decline any insurance proposal or to offer different premium and terms from those quoted dependent on the information you have provided.

    Failure to disclose relevant information may result in the non-payment of a claim and all cover under the policy being cancelled