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Personal Details
1. First Name *
2. Last Name *
3. Date of Birth (DD/MM/YYYY) *
4. Employer *
5. Occupation *
6. Rank *
7. Home Address *
8. Postcode *
9. Phone Number (Mobile) *
10. Fax No.
11. Email *
12. Correspondence Address (if different)
13. IPA Membership Number and start date *
14. Can you confirm that you are a current member of the IPA? *	Yes, I'm a Full 1 member Yes, I'm a Full 2 member Yes, I'm an Associate No, I'm not a member
15. Have you ever had legal expense insurance cover? *	Yes No
16. Has any insurer ever declined a proposal, refused renewal, cancelled a policy or imposed special conditions? *	Yes No
17. Do you have any disputes ongoing or any potential disputes in connection with your occupation as a pilot? *	Yes No
18. If you answered "Yes" to Q17 please provide full details including action taken to date, Solicitor/Barrister dealing with the case etc.

Declaration
I, the proposed Applicant for DAS UK Holdings Limited described above do hereby declare that all statements made in the Personal Statement concerning myself are complete and true and that they are correctly and fully recorded and that no material information has been withheld or omitted. I give permission that all data provided may be held, processed and shared in order to arrange insurance and/or premium finance (if applicable).
I have read and agreed the Declaration above (TICK BOX) *

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