The New India Assurance Company Limited
Registered & Head Office:New India Assurance, 87,M.G. Road,Fort,Mumbai - 400 001

Declaration Form for Aviation Personal Accident Policy For Crew Members
(To be completed by each person to be insured and to form part of the Aviation Personal Accident Proposal Form)

1. Name :

2. Age till last birthday :

3. What is the exact nature of your duties :

4. If you are pilot or navigator or flight
engineer state
a. Number and type of license :
b. Date of license :
c. By whom granted :
d. Date of expiry of license :
e. Type/s of aircraft in respect of
which the license is granted :
f. Date of last medical examination
for the license :

5. Has your license been suspended or
withdrawn or have you ever been charged
with any offence under the air navigation
regulations? :
If so, give details :

6. Give details of your flying experience : Aircraft Total No. of Hours Flown

7. Have you been involved in any aviation
accident during the last 5 years? :
If so, give details of each accident :

8. Have you made any claim during the last
5 years under an Aviation Personal
Accident Policy :
If so, give details of each claim :

9. Has any insurance company at any time,
a. Declined your proposal for aviation
P.A. Policy or Life Insurance :
b. Required an increased premium or
imposed special conditions? :
c. Cancelled or refused to renew
your insurance? :
If answer to a, b or c is “yes”,
Please give details :

10. What are the types of aircraft you
contemplate flying? :

I, the undersigned, hereby declare that all the above particulars are true and complete in every respect, that I am in good health and free from physical infirmity or defect of any kind, that I am and always have been of temperate habits, and that I have not withheld or suppressed any information regarding the proposal.

Place:

Date: (Signature of the person to be insured)

Agency Policy No.

Proposal Form for Aviation Personal Accident Policy
(For pilots, navigators, aircraft flight engineers, aircraft flight technicians & other crew members)

1. Proposer’s Name in full :

2. Proposer’s Address :

3. Proposer’s business or occupation :

4. Persons to be insured
(A declaration form in the prescribed format should be completed by each person to be insured and attached to this proposal)

SL. Name Age last Designation/ Capital Table of
No. Birthday Occupation Sum Insured Benefits
(In years) (Rs.)

5. Period of Insurance From :
To :

6. Nature of flying to be done :

7. Geographical limits to which
flying will be confined :

8. Has any of the persons to be insured,
to your knowledge, any physical
defect or infirmity of any kind? :

9. Has any insurance company at any time,
a. Declined your proposal? :
b. Required an increased premium
or imposed special conditions? :
c. Cancelled or refused to renew
your insurance? :

10. Has any aircraft owned or operated
by you ever met with an accident
involving injuries to passengers
and/or crew members? :

11. Is the insurance to apply on
24 hours basis, or to apply to
flying risks only? :

12. The proposer may, at his option complete this column.
If the proposer is also the insured person, this column should be completed.

I, ____________________________________do hereby assigns the monies payable by The New India Assurance Company Limited in the event of insured person’s death to _______________________________, ___________________(relationship to the insured) and I declare that his/her receipt shall be sufficient discharge to the company.

(Signature of the Insured)

Witness Signature of the witness:

Name of the witness :

Address of the witness :

I/We hereby declare that the above statements are true and complete. I/We agree that this
proposal and declaration form (signed by the person/persons) to be insured) shall be the basis of
the contract between me/us and the insurance company. I/We further agree to accept a policy
subject to the conditions stipulated therein by the insurance company.

Place:

Date: (Signature of the Proposer)