Ardmore Airport, Private Bag 14, Papakura, 
Auckland, New Zealand

Tel: +64 9 298-8206 • Fax: + 64 9 298 -8218
Email: insure@avsure.co.nz

                                    PILOTS TERM LIFE QUESTIONNAIRE

 Name:     _____________________________________________________         

Address:   _____________________________________________________

                 _____________________________________________________

 Phone:     ______________________      Fax:    _____________________

E-mail:      ______________________      Date of Birth: _______________

Height:      ______________________      Weight: ____________________

Gender:         Male/Female

Smoker:        Yes/No    If yes, kind and amount  ______________________

_______________________________________________________________

PILOT INFORMATION

Please indicate classifications of licence/rating held:

                                                          (Indicate with an X)

Student Pilot 

£

Private Pilot    

£

Commercial Pilot

£

Airline Transport   

£

Instructor:       Fixed Wing

£

                      Helicopter     

£

Agricultural Pilot – Fixed Wing  

£

Agricultural Pilot – Helicopter   

£

 Total Hours Logged:                 ______________________ 

Hours flown last 12 months:      ______________________

Date of Last Medical:                ______________________

Signature:  _______________________________        Date: ___________________