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)

HELICOPTER TYPE/MAKE

YEAR

AGREED VALUE

PAX SEATS

REGN

LIABILITIES

Third Party Indemnity Required $

USES

YES/NO

HOURS PA

USES

YES/NO

HOURS PA

Private/Business Pleasure

WARS

Rental for Private/Business

Aerial Agriculture

Survey/Photography

- Bucket Fertilising

Charter, Air Transport

- Spraying

Pilot Training &Instruction

SAR/Air Ambulance

Slung Loads

Corporate Use

Total Estimated Hours

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

NAME

AGE

LICENCE

ROTARY WING TT

TURBINE TT
(IfApplicable)

ON TYPE TT

CLAIMS/ACCIDENTS/CAA VIOLATIONS

OPEN PILOT WARRANTY    (if required please indicate)

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

SIGNED

TITLE

NAME

DATE