FIXED WING PILOTS EXCESS INSURANCE PROPOSAL FORM

INSURED NAME

First Name

Last Name

IDENTITY NUMBER

INSURED ADDRESS

INSURED CONTACT NUMBER

INSURED EMAIL ADDRESS

INCEPTION DATE

YYYY

ASSOCIATED FLIGHT TRAINING SCHOOL

NAME OF FLIGHT TRAINING SCHOOL

OTHER - FLIGHT SCHOOL

If your school was not listed as an option above, please fill in below. Type X here if your school was listed above.

PLEASE ADVISE OF ANY ACCIDENTS AND/OR INCIDENTS AND/OR LOSSES AND/OR CLAIMS IN THE LAST 5 YEARS?

LIMITS OF INDEMNITY AND PREMIUM

(NOTE: Including VAT) Please select Limit of Indemnity and Premium

SELECT NUMBER OF MONTHS

PREMIUM PAYMENT OPTIONS

I/We agree to pay the premium by means of (please select the appropriate box):

READ BEFORE SUBMISSION

PLEASE TAKE NOTE THAT THERE IS A ONCE OFF ADMINISTRATION FEE OF ZAR 100.00 (including VAT) PLEASE NOTE THE MINIMUM PERIOD FOR ANY DEBIT ORDER ARRANGEMENT IS 3 MONTHS. ANY COVERAGE ISSUED FOR LESS THAN A 3 MONTH PERIOD WILL BE INVOICED AS A ONCE-OFF ARRANGEMENT. IN THE EVENT OF A CLAIM THE FULL ANNUAL PREMIUM, LESS ANY PREMIUMS ALREADY PAID, WILL BECOME DUE AND PAYABLE TO THE HOLLARD INSURANCE COMPANY LIMITED. IN THE EVENT OF A CLAIM THE COVERAGE AFFORDED BY THIS POLICY IS SUBJECT TO REINSTATEMENT AND PRIOR AGREEMENT BY THE HOLLARD INSURANCE COMPANY LIMITED.