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

Proposal Form for Loss of Flying License Insurance

Proposal No: Policy No:

A. Surname:

Christian Names:

Address:

Date of Birth:

Occupation: Flight Category:
Captain/Pilot:
First/Second Offer:
Navigation Officer:
Radio Officer:
Flight Engineer/Instructor/ Glider Instructor
(delete whichever is inappropriate)

What is your present total remuneration
from your above stated occupation?

B. Name and address of present Employer:

If freelance state: -
1. Type of Employment anticipate and all remunerated occupation:

2. Type of flying during past 2 years e.g. Air Line, Crep-spraying, Helicopter etc

C. Type and number of license:
By whom granted?
Date of Issue:
Date of last renewal:
(This must not be confused with the date of last medical examination of such renewal. The date of actual renewal must be given)

D. State whether or not you already have a Loss of License Insurance Policy, (State “Yes” or “No”. If Yes, state: -
a. With whom?
b. For what amount?
c. Date of expiry of the Insurance:
d. Particulars of Insurance required:

E. PARTICUALRS OF INSURANCE REQUIRED
a) For What Sum?
b) For What Period? From To

NOTE: This insurance may be invalidated by the existence of another Loss of License insurance unless prior agreement is obtains from the "NEW INDIA ASSURANCE CO. LTD."
________________________________________________________________________
I hereby declare that to the best of my knowledge I have not sustained any personal injury whatsoever and I am not at the present time and have not been at any time afflicted any illness whatsoever (including temporary or otherwise of my physical aural or eye condition) except as detailed below: -

I further declare that the certificate of validity forming part of my above mentioned License has never been invalidated for any period, except as stated below: -

I warrant that the above statements and particulars are true and thereby agree that this Declaration shall be held to be promissory and shall form the basis of the contract between me and the New India Assurance co. Ltd. and I am willing to accept a policy subject to the terms, exceptions and condition prescribed by the Company therein, and to pay the premium thereon.

DATE_______20 PROPOSER'S SIGNATURE:
_________________________________________________________________________
WARNING TO ALL PROPOSERS

In your own interest great care must be taken in completing the declaration set out above. Non disclosure or incomplete disclosure of any fact which is or may be material to the New India Assurance Co. Ltd. in deciding whether to accept your proposal for insurance may invalid to the policy and cause you to be deprived of all benefits thereunder.

THE NEW INDIA ASSURNACE COMPANY LIMITED reserves the right to impose special conditions or refuse to accept a proposal form.
________________________________________________________________________
SPACE FOR MEDICAL HISTORY
(IF NIL, State NIL)

(State all illnesses of whatsoever nature and all accidents involving injury and give result of last cardiograph examination with date in all cases)

DATE: __________20 PROPOSER'S SIGNATURE:

SPACE FOR DETAILS DURING WHICH THE CERTIFICATE OF VALIDITY FORMING PART OF THE PROPOSERS' LICENCE HAS BEEN INVALIDATED (State date and cause: If NIL state NIL.)

DATE: _______20 PROPOSER'S SIGNATURE: