|
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) |
|
BALLOON TYPE/MAKE |
YEAR |
AGREED VALUE |
MAX. PAX CAPACITY |
REGN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LIABILITIES |
Third Party Indemnity Required? ($500,000)
|
YES/NO |
|
Do you require Noise Cover? (Max.
NZ$50,000) |
YES/NO |
|
Do you require Material Damage on
Basket/Balloon? |
YES/NO |
|
USES |
YES/NO |
HOURS PA |
USES |
YES/NO |
HOURS PA |
|
Private/Leisure |
|
|
Pilot Training |
|
|
|
Rental |
|
|
Parachuting |
|
|
|
Photography |
|
|
|
|
|
|
Joy Rides, Air Transport |
|
|
Total
Estimated Hours |
|
|
PILOTS
– Please provide details as to pilots names, age, qualifications, total
experience (years/hours), total balloon experience. Any other information that may qualify
the risk in the eyes of the insurer |
|
NAME |
AGE |
QUALIFICATION |
EXPERIENCE
(YEARS) |
EXPERIENCE
(HOURS) |
ON TYPE |
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) |
|
|
|
|
|
|
Home
|
