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Instructions

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
1. Surname
2. First name(s)
3. Rank
4. Address in full
5. Telephone
6. Email
7. Date of birth (dd/mm/yyyy)
8. Gender Male   Female
9. Country of birth
10. Main employer
11. Date cover to commence (dd/mm/yyyy)
12. Annual taxable earned income from your main employer
13. Any other earned income from flying Yes   No
13 a. If Yes, please provide further details.
14. During a period of disability, does your employer provide contractual sick pay? Yes   No
14 a. If Yes, 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? Yes   No
15 a. If Yes, how much and for how long?
16. During a period of disability will you receive any other regular income? Yes   No
16 a. If Yes, 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? Yes   No
17 a. If Yes, please give name of insurer(s), policy number(s) and benefit payable?
18. Type of aircraft flown (please list all which apply) Fixed Wing  
Rotor Wing (On Shore)  
Rotor Wing (Off Shore)  
18 a. Please specify type, number, country of issue and whether any limitations apply or have applied previously
TYPE NUMBER COUNTRY ISSUED LIMITATION

Basis of Cover
19. Do you require Pilot Income Protection? Yes   No
19 a. Sum to be Insured Pilot Income Protection
19 b. Please specify the waiting period in days 60   90   120   150   180  
20. Do you require Personal Accident? Yes   No
20 b. Sum to be Insured Personal Accident
SUMS INSURED NAME DATE OF BIRTH
Pilot
Spouse
21. Do you require Loss of Licence? Yes   No
21 a. Sum to be Insured Loss of Licence
22. Is this proposal: Your first   An additional
22 a. If this is an additional amount, please confirm the existing policy number and amount insured.

Medical Information
23. Do you hold a current medical certificate? Yes   No
24. What is your height (cm)?  
25. What is your weight (kg)?  
26. Has there been any significant change in weight in the last year (± 6.5kg)? Yes   No
26 a. If yes please give details
27. Date of last medical examination (dd/mm/yyyy)  
28. Were you advised of any abnormality, referred for additional tests, specialist examination or asked to follow any treatment or diet plan? Yes   No
28 a. If yes please give details
29. Date of last electrocardiograph taken as required by the Licensing Authority (dd/mm/yyyy)  
30. Were you advised of any abnormality, referred for additional tests, specialist examination or asked to follow any treatment plan? Yes   No
30 a. If yes please give details
31. Have you been investigated, diagnosed or treated for any of the following
(a) Cancer, leukemia, Hodgkin’s disease, lymphoma, or any malignant condition? Yes   No
(b) A mole or freckle that has bled, caused pain or changed in appearance or any lump or growth? Yes   No
(c) Heart disease (including heart attack, angina, valve defect, heart defects from birth or heart surgery)? Yes   No
(d) Chest pain, irregular heart beat, raised blood pressure or raised cholesterol? Yes   No
(e) Any other chest complaint? Yes   No
(f) Disease or disorder of the arteries (including disease in the legs or of the aorta)? Yes   No
(g) Stroke, Transient Ischaemic Attack [TIA] brain haemorrhage or brain injury? Yes   No
(h) Asthma, bronchitis, lung or any other respiratory disorder? Yes   No
(i) Multiple Sclerosis, optic or retrobulbar neuritis, Parkinson’s disease, paralysis, epilepsy, Alzheimer’s disease, dementia, bell’s palsy or cerebral palsy? Yes   No
(j)Any other disorder of the central nervous system not already mentioned? Yes   No
(k) Numbness, loss of feeling or tingling of the limbs or face, loss of balance or coordination? Yes   No
(l) Seizures, fits, fainting, unexplained loss of consciousness or blackouts? Yes   No
(m) Mental illness or psychological problems that have required any kind of medical attention, time off work, hospital treatment or referral to a psychiatrist? Yes   No
(n) Depression, anxiety, stress, insomnia, fatigue (including chronic fatigue syndrome [CFS] / myalgic encephalopathy [ME]) or nervous breakdown? Yes   No
(o) Any disorder of the eyes or ears including blurred or double vision or impaired hearing? Yes   No
(p) Gout, arthritis, back pain, sciatica, neck, knee or wrist pain? Yes   No
(q) Any other disorder of the joints, bones or muscles (including repetitive strain injury)? Yes   No
(r) Diabetes, abnormal glucose tolerance or sugar in the urine? Yes   No
(s) Disorder of the kidneys, bladder or the genitourinary system (including blood or protein in the urine and urinary tract infections)? Yes   No
(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)? Yes   No
(u) Any blood disorder or anaemia? Yes   No
(v) Thyroid or other glandular disorder? Yes   No
(w) Any gynecological, menstrual or breast problems (e.g. breast lumps)? Yes   No
(x) Any prostate problems or problems relating to the breast tissue? Yes   No
(y) Have you ever tested positive for HIV, Hepatitis B or C or are you awaiting the results of such test? Yes   No
(z) Any disease which was transmitted sexually? Yes   No
32. 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? Yes   No
If yes 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? Yes   No
If yes 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? Yes   No  
If yes please give details
33. 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? Yes   No
33 a. If yes please give details
34. Are you aware of any symptoms or complaints for which you have not consulted a doctor or received treatment? Yes   No
34 a. If yes please give details  
35. Have you ever been advised by your doctor or another medical practitioner to drink less alcohol? Yes   No
35 a. If yes please give details  
36. Have you used any form of tobacco or nicotine products in the last twelve (12) months? Yes   No
36 a. If Yes, please give details of quantity per week  
37. 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? Yes   No
37 a. If Yes, please give details including age when diagnosed  
38. 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? Yes   No
38 a. If Yes, please give details  
The Insurer may require additional medical information. If you have completed any section declaring medical history, please complete the following:
39. Usual Doctor or General Practitioner’s name and contact address  
40. Consultant name and contact address  

Notice of Statutory Rights Under the Access to Medical Reports Act 1988

Please read this document Notice of Statutory Rights.
I have read the Notice of Statutory Rights (TICK BOX) *

I have been informed of my rights under the Access to Medical Reports Act 1988 and hereby consent to the Insurer obtaining medical reports in connection with this application.
Do you wish to see the report before it is sent to the insurer? Yes   No

Please read this document AXA XL Fair Processing Notice.
I have read the AXA XL Fair Processing Notice (TICK BOX) *

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 insurer and the premium is paid. The insurer reserves 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 (TICK BOX) *

 

 
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