Pilots Insurance - Village 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

Which airline do you fly for?

How did you hear about us?

1. Surname

2. First Name(s)

3. Rank

4. Address in Full

House or Apartment Number

Building name

Street

District

City

Country

Postcode

5a. Phone Number Country Code

5b. Phone Number

6. Email

7. Date of Birth

Day
Month
Year

8. Gender
MaleFemale

9. Country of Birth

10. Main Employer

11. Date cover to commence

Day
Month
Year

12a. Annual taxable earned income from your main employer

12b. Income Currency

13. Any other earned income from flying
NoYes

Please provide further details

14. During a period of disability, does your employer provide contractual sick pay?
NoYes

How much and for how long

15. During a period of disability, are you entitled to benefit from any other loss of licence, disablement or accident insurance policy which pays a temporary benefit?
NoYes

How much and for how long

16. During a period of disability, will you receive any other regular income?
NoYes

How much and for how long

17. Are you entitled to benefit from any other loss of licence, disablement or accident insurance policy which pays a lump sum benefit only?
NoYes

Name of insurer(s), policy number(s) and benefit payable

18a. Type of aircraft flown (please select all which apply)
Fixed WingRotor Wing (on shore)Rotor Wing (off shore)

18b. Please specify type, number, country of issue and whether any limitations apply or have applied previously. If none, please enter 'none'.

Type

Number

County Issued

Limitation

Do you have more than one type rating?
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

19. Do you require Pilot Income Protection?
NoYes

Sum to be insured - Pilot Income Protection USD$

Please specify waiting period in days

20. Do you require Personal Accident?
NoYes

Pilot Sum USD$

Pilot Insured Name

Pilot Date of Birth

Day
Month
Year

Do you require cover for spouse?
NoYes

Spouse Sum USD$

Spouse Insured Name

Spouse Date of Birth

Day
Month
Year

Do you require cover for your children?
NoYes

Child 1 Sum USD$

Child 1 Insured Name

Child 1 Date of Birth

Day
Month
Year

Child 2 Sum USD$

Child 2 Insured Name

Child 2 Date of Birth

Day
Month
Year

Child 3 Sum USD$

Child 3 Insured Name

Child 3 Date of Birth

Day
Month
Year

21. Do you require Loss of Licence?
NoYes

Sum to be insured - Loss of Licence USD$

22. Do you require Permanent Inability to Fly Insurance?
NoYes

Sum to be insured -Permanent Inability to Fly insurance USD$

23. Is this proposal
Your FirstAn Additional

Please confirm the existing policy number and amount insured

MEDICAL INFORMATION

24. Do you hold a current medical certificate? NoYes
25. What is your height (cm)?
26. What is your weight (kg)?
27. Has there been any significant change in weight in the last year (± 6.5kg)? NoYes

Please give details

28. Date of last medical examination

Day
Month
Year

29. Were you advised of any abnormality, referred for additional tests, specialist examination or asked to follow any treatment or diet plan? NoYes

Please give details

30. Date of last electrocardiograph taken as required by the Licensing Authority (dd/mm/yyyy)

Day
Month
Year

31. Were you advised of any abnormality, referred for additional tests, specialist examination or asked to follow any treatment plan? NoYes

Please give details

32. Have you been investigated, diagnosed or treated for any of the following
(a) Cancer, leukemia, Hodgkin’s disease, lymphoma, or any malignant condition? NoYes
(b) A mole or freckle that has bled, caused pain or changed in appearance or any lump or growth? NoYes
(c) Heart disease (including heart attack, angina, valve defect, heart defects from birth or heart surgery)? NoYes
(d) Chest pain, irregular heart beat, raised blood pressure or raised cholesterol? NoYes
(e) Any other chest complaint? NoYes
(f) Disease or disorder of the arteries (including disease in the legs or of the aorta)? NoYes
(g) Stroke, Transient Ischaemic Attack [TIA] brain haemorrhage or brain injury? NoYes
(h) Asthma, bronchitis, lung or any other respiratory disorder? NoYes
(i) Multiple Sclerosis, optic or retrobulbar neuritis, Parkinson’s disease, paralysis, epilepsy, Alzheimer’s disease, dementia, bell’s palsy or cerebral palsy? NoYes
(j) Any other disorder of the central nervous system not already mentioned? NoYes
(k) Numbness, loss of feeling or tingling of the limbs or face, loss of balance or coordination? NoYes
(l) Seizures, fits, fainting, unexplained loss of consciousness or blackouts? NoYes
(m) Mental illness or psychological problems that have required any kind of medical attention, time off work, hospital treatment or referral to a psychiatrist? NoYes
(n) Depression, anxiety, stress, insomnia, fatigue (including chronic fatigue syndrome [CFS] / myalgic encephalopathy [ME]) or nervous breakdown? NoYes
(o) Any disorder of the eyes or ears including blurred or double vision or impaired hearing? NoYes
(p) Gout, arthritis, back pain, sciatica, neck, knee or wrist pain? NoYes
(q) Any other disorder of the joints, bones or muscles (including repetitive strain injury)? NoYes
(r) Diabetes, abnormal glucose tolerance or sugar in the urine? NoYes
(s) Disorder of the kidneys, bladder or the genitourinary system (including blood or protein in the urine and urinary tract infections)? NoYes
(t) Any disorder of the digestive system, gall bladder, liver, stomach, spleen, pancreas, bowel (including ulcers, hepatitis, colitis or Crohn’s disease or any other form of bowel disease)? NoYes
(u) Any blood disorder or anaemia? NoYes

(v) Thyroid or other glandular disorder? NoYes

(x) Any prostate problems or problems relating to the breast tissue? NoYes

(w) Any gynecological, menstrual or breast problems (e.g. breast lumps)? NoYes

(y) Have you ever tested positive for HIV, Hepatitis B or C or are you awaiting the results of such test? NoYes
(z) Any disease which was transmitted sexually? NoYes

33. Please also answer the following

(a) Are you currently taking any form of medication, prescribed or otherwise or following any special diet or treatment or have you taken any form of medication for longer than twenty one (21) days? NoYes

Please give details

(b) Do you have any further disclosures to make with regard to any medical investigation, test or consultation, advice, counselling, operation, medication or treatment that you have had or been advised to have or are currently having, but have not already mentioned? NoYes

Please give details

(c) Have you any current symptoms, medical disorder or abnormality medical investigation, for which you have not sought medical advice but intend to, but have not already mentioned? NoYes

Please give details

34. During the last five (5) years have you been off work, unable to carry out your normal duties due to sickness or injury for more than twenty one (21) days at any one time, other than previously stated? NoYes

Please give details

35. Are you aware of any symptoms or complaints for which you have not consulted a doctor or received treatment? NoYes

Please give details

36. Have you ever been advised by your doctor or another medical practitioner to drink less alcohol? NoYes

Please give details

37. Have you used any form of tobacco or nicotine products in the last twelve (12) months? NoYes

Please give details of quantity per week

38. Have your parents, brothers or sisters, before the age of sixty five (65), died or suffered from, or had any investigations for heart disease, stroke, polycystic kidney disease, cancer or tumour or diabetes, Multiple Sclerosis or Polyposis of the colon? NoYes

Please give details including age when diagnosed

39. Have you ever had an application for loss of licence, life, critical illness or income protection insurance postponed, declined, accepted with an increased premium or on special terms? NoYes

Please give details

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

40. Usual Doctor or General Practitioner’s name and contact address

41. Consultant name and contact address

PRIVACY & COOKIES

Please read this document Millstream Privacy and Cookies.

I have read the Millstream Privacy & Cookies statement

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

I have read and agreed the Declaration above