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

Agency Policy No.

PROPOSAL FORM POR AIRCRAFT AND/OR AVIATION LIABILITIES INSURANCE

(DEFINITE ANSWERS SHOULD BE GIVEN FOR ALL QUESTIONS. NO COLUMN SHOULD BE LEFT BLANK OR COMPLETED WITH A '-' (DASH))

1. Proposer's name in full:

2. Proposer's address:

3. Proposer's business:
or occupation

4. Details of aircraft to be insured
Air Frame Engines
Passenger Seating Capacity Number & Date of issue of last renewal of C of A Number and Type Maximum All Up weight of aircraft in kgs
Make, Type & Series No. Year of construction Licensed Declared for the purpose of this insurance Registration/
Identification Marks

5. Value of the aircraft

Year of purchase Price Paid
Rs. Present value of the aircraft with standard instruments and equipment (Rs.) Extra equipment and accessories fitted to or carried in the aircraft

Details Value Total value of the aircraft for the purchase of insurancee

6. Purpose for which the
aircraft will be used

7. Geographical limits for
which mover is required

8. Will aircraft be flown at night ?

9. By whom will the maintenance and
running repairs be carried out

10. (a) Where will the aircraft
usually be kept ?
(b) Is the aircraft normally
kept in a hanger ?
(c) If so, state type of
construction of hanger

11. Will the aircraft be taxied by persons other than licensed pilots or competent licensed engineers?

12. Have you entered into any agreement with any party whereby liability is assumed or denied in respect of the operations of the aircraft ?
If so, give details

13. Has any insurance company at any time,
(a) Declined your insurance proposal?
(b) Cancelled or refused to renew your policy?
(c) Required an increased premium or imposed any special condition?

If answer to (a) or (b) or (c) is “ Yes" Please give details,

14. Please state details of all accidents/losses during last 5 years.
Date of Accident Brief details of accident Cost of estimate of repairs to Aircraft (Rs.) Amount of liability claims incurred (Rs.)
Third Party Passenger

15. Give details of pilot who will fly the aircraft.
Pilot Pilot Pilot
Name
Age
Types of aircraft flown
Flying experience
(in hours)
Total Day:
Total Night:
During last 3 months:
On type & make of aircraft proposed for insurance:

Current License
Date of expiry
Classification

Details of accidents, if any, during last three years

16. Details of insurance required:
(A) SECTION 1 - LOSS OR DAMAGE TO THE AIRCRAFT
Whether cover required:
If so, risks to be covered:
(State "Flight", Taxying" "Ground" "Moored" as the case may be)

(B) SECTION II - THIRD PARTY LIABILITY
Whether cover required:
If so, Limit of Indemnity (any one accident):

(C) SECTION III PASSENGER LIABILITY
Whether cover required:
Limit of liability per passenger:
Whether cover required on 'Legal Liability" basis or "Admitted Liability” (voluntary settlement) basis:
Baggage Liability
Whether cover required:
Limit of Indemnity per passenger:

17. (a) Do you require Hull War Risks cover?
(b) If full Hull War Risks cover is not required, do you require limited coverage for Malicious Damage/Strikes, Riots & Civil Commotion/ Sabotage/Hi-jacking ?

18. PERIOD OF INSURANCE From___________________ To_______________

DECLARATION: I/We warrant that the abovementioned aircraft is/are my/our property, and the statements and particulars given are true and that no material information has been withheld or suppressed, and I/We agree that this proposal and declaration shall be the basis of the contract between me/us and the Insurance Company and to accept a policy subject to terms, conditions and exclusions prescribed therein.

Signature of the Proposer