INSURANCE HOUSE, PSAILA STREET, B KARA BKR 02, MALTA HELICOPTER QUESTIONNAIRE

Transcription

1 INSURANCE HOUSE, PSAILA STREET, B KARA BKR 02, MALTA. TEL: (+356) , (+356) FAX: (+356) info@islandins.com - HELICOPTER QUESTIONNAIRE

2 HELICOPTER MULTI RISK QUESTIONNAIRE 1. Proposer Details Name Trading As (if applicable) ID Card No/Passport No/ Company Reg. No. Address Telephone Fax Website 2. Details of Aircraft Make Model Registration Date of Manufacture Number of Seats Pilot: Passengers: 3 Coverage Liability Combined Single Limit (Third Party & Passenger Cover) Hull Ordinary Risk Hull War Risk Pilot Individual Accident (Death & Permanent Disability) Individual Passenger Insurance (Death & Permanent Disability) Legal Protection

3 4A. Designated Pilots Surname Name Owner / Co-Owner Yes No Yes No Yes No Yes No Yes No Date of Birth Date of Qualification Total Flight hours No. of hours on a singlemotor aircraft No. of hours on a multi-motor aircraft No. of hour on Helicopters No. of hours on a Turbine Engine Helicopter No. of hours on specified Make & Model Robinson Training Yes No Yes No Yes No Yes No Yes No Claims (See 5 Claims) Yes No Yes No Yes No Yes No Yes No Punished Infractions (See 5 Claims) Yes No Yes No Yes No Yes No Yes No 4B. All Pilots Total Flight Hours Helicopters Turbine Helicopters specified Make & Model 5. Claims and Punished Infractions (Last 5 years for pilots and Insured) Date of Loss Aircraft Type Cause Cost Version IIB Page 3 of 5

4 6. Type of Usage Private, pleasure and business Commercial, charter Flying Club Work, including/excluding Ab-Initio instruction Rental (please specify) Aerobatics including/excluding displays and competitions Any other use (please specify) 7. Other Information Anticipated annual utilisation (hours) per aircraft (Split between uses if applicable) Normal area of Operation/ Geographical Limits of use Is there any outstanding finance/loan on the aircraft? Where is the aircraft based? If yes, with whom and how much? Is aircraft hangared? Who maintains the Aircraft? Are you presently insured? If yes, with whom? What is the renewal date of the existing policy/ies All material facts must be disclosed to your brokers whether or not the subject of a specific question above. A material fact is one which an Underwriter would regard as likely to influence the acceptance or assessment of the proposal. Non disclosure or misrepresentation of a material fact may result in the insurance being void. If you are in any doubt about whether facts would be considered as material, you should disclose them. I declare that the above particulars and answers are correct and complete in every respect to my knowledge and belief. I agree that a proposal form would need to be completed prior to placing of risk. The submission of this form does not bind the Proposer to complete the insurance. Signature Full Name & Position Date DATA PROTECTION only processes personal data in accordance with the Data Protection Act. By completing this form and sending it to Island Insurance Brokers Ltd, you consent to processing your personal data in accordance with our Privacy Policy. Please view our Privacy Policy at before submitting this form. Version IIB Page 4 of 5

5 OTHER INFORMATION About Us Island Insurance Brokers Ltd is one of the leading insurance brokers in the local market. We have commenced operations in 1989 and since then we have grown both in quality and quantity of services provided to our clients. Our services now include Insurance Broking, Risk Management and Insurance Consultancy. Island Insurance Brokers is one of the very few local companies having a specialised Marine and Aviation team handling only this highly technical line of business. This team takes care of the insurance requirements of a wide variety of clients, involved in the Maritime and Aviation sectors. Our team is well experienced in tailoring your Aircraft Insurance Policy to cater for your specific requirements. Our local and international connections allow us to secure competitive terms from both the Maltese and International Insurance markets. As a client of Island Insurance Brokers you will be assured an open-minded, flexible and greatly experienced approach to your marine insurance matters. Your Contacts at Island Insurance Brokers: Norbert Cordina Manager T E. n.cordina@islandins.com Amanda Lia Broker/Claims T E. a.lia@islandins.com Luca Camilleri Assistant Broker T E. l.camilleri@islandins.com Version IIB Page 5 of 5