Your attention is drawn to the declaration at the foot of this form. it is important that all sections of this proposal form should be fully completed even if it is for renewal of or for an amount additional to an existing insurance. You should declare all conditions even though you have been declared fit. You should not omit to mention investigations where you have been told that the result is satisfactory. Failure to disclose material information may invalidate the policy.
A.
Surname:
First Names:
Rank:
Address (in full):
Post Code:
Tel (home):
Date of Birth:
Weight (current):
Height:
Height (12 months ago):
Annual Salary (including bonuses):
B.
(i) Employer:
(ii) Type of Duties / aircraft (please tick all which apply) Commercial: Yes Private: Yes Instruction: Yes Fixed Wing: Yes Rotor Wing: Yes
C.
All Current Licences Held (please specify type, number country of issue):
D.
Sum to be Insured: 100.000 USD Yes 150.000 USD Yes 200.000 USD Yes 300.000 USD Yes
E.
Please state if this proposal is: a) your first proposal to this company Yes b) for renewal of an additional amount to an existing insurance Yes (if (b) state existing Policy No. and amount insured and agent):
F.
Are you entitled to benefit from any other "Loss of Licence, Permanent Health or Aircrew Disability Insurance?" Yes No If Yes, state type and the amounts insured:
G.
Do you hold a current medical certificate ? Yes No
Has any limitation or endorsement been imposed on any Licence you hold or have held? Yes No If Yes, give details:
H.
(i) Date of last aircrew medical examination
(ii) Date of last electrocardiograph taken as required by the Licensing Authority.
(iii) Were you advised of any abnormality in or revealed by the examination Yes No If Yes, give details:
I.
Have you ever been grounded or had any licence invalidated for medical reasons? Yes No If Yes, give dates and details:
J.
Have you ever been required to take additional tests at or after a medical examination, been referred for specialist investigation, had the issue or renewal of any medical certificate deferred, had to return for examination at less than the normal interval of time or been ordered to take drugs or follow any special diet or treatment? Yes No If Yes, give dates and details:
K.
Have you consulted any medical practitioner or attended hospital during the last five years other than for the purpose of obtaining or renewing your licence? Yes No If Yes, state when and for what reason:
L.
Medical History.
All medical conditions must be stated giving all disabilities illnesses and accidents, with appropriate dates. if you have no medical history to declare state None:
None
M.
Are you aware of any deterioration in your health including hearing, eyesight and blood pressure? Yes No If Yes, give details:
N.
What is your average daily consumption of alcohol?:
O.
Have you smoked cigarettes, cigars or a pipe in the last 12 months? Yes No If Yes, state average daily quantity:
P.
Has either of your parents or brothers or sisters had diabetes, heart disease, high blood pressure or a mental or nervous disease? Yes No If so, please give full details, including approximate age at onset:
Q.
Has any Insurance Company or Underwriter:
(i) declined of deferred a Proposal from you?
(ii) charged or quoted more than standard rates?
(iii) cancelled or declined to renew your insurance
Yes No If Yes, give details:
R.
Access to Medical Report Act, 1988 (please see below for further details)
I do/do not wish to see the report before it is sent to the Insurers*
*delete as applicable.
I have been informed of my rights under the Access to Medical Reports Act 1988 and I hereby consent to the Insurers obtaining medical reports in connection with this application.
I hereby declare that to the best of my knowledge and belief the answers to the foregoing questions whether in my own handwriting or not are true and complete and that I have not withheld any information which might influence the decision of the Insurers with regard to this proposal. I agree that this proposal and declaration shall be the basis of the Contract between me and the Insurers ifa policy is issued.
I have read I accepted: Yes
Dated:
The Company reserves the right to impose special conditions or refuse to accept a proposal for insurance.
To process your application we may need to obtain a medical report from any doctor who has attended you. Y ou can withhold your consent for us to obtain the report, but without it cover may be restricted. Y ou are responsible for any fees incurred by us in obtaining such reports.
If you consent, you can see the medical report before it is sent to us. W e will inform you when we write to the doctor, and you need to obtain your copy within the next 21 days. If after 21 days the doctor has not heard from you, he can send his report directly to us, and you can still request a copy any time during the following six months for which you may be charged.
If you see the report within the 21 days, the doctor must obtain your consent before sending it to us. Y ou can ask the doctor to amend any part of the report which is incorrect or misleading. Y ou can attach a statement of your views on any part of the report where you and the doctor are not in agreement.
The doctor does not have to let you see any part of the report which could cause serious harın to your physical or mental health, or that of others, or would indicate the doctor's intentions towards you, or if information about you which has been supplied by another person, other than a health professional, would be revealed.
If the doctor withholds any part ofthe report from you, he must inform you ofthis fact. Ifit is the whole report which is affected, the doctor must not send it to us unless you consent to this.
If you do not wish to see the report, the doctor will send it to us immediately, but he must keep a record of the report for a peri od of six months, and you may apply to see a copy of the report during this time.
Müşteri Adı Soyadı:
Kart Sahibi TC:
E-Mail Adres:
GSM (Cep) / Sabit Telefon:
Tarih:
Kartın Alındığı Banka:
Kart No (16 haneli kredi kartı numaranız):
Son Kullanma Tarihi: AY: YIL:
Güvenlik Kodu:
Varsa Taksit Sayısı:
Ödeme Tutarı (Rakamla):
Ödeme Tutarı (Yazıyla):
KVKK Metnini okudum ve tüm ayrıntılarıyla bilgilendirildim.
Okudum Kabul Ediyorum: Yes
