ROTOR WING PILOTS EXCESS INSURANCE PROPOSAL FORM

Please provide the following material information below which is required by Insurers.

INSURED NAME

First Name

Last Name

IDENTITY NUMBER

INSURED ADDRESS

INSURED CONTACT NUMBERS

INSURED EMAIL ADDRESS

INCEPTION DATE REQUIRED

SUM INSURED REQUIRED

ASSOCIATED FLIGHT TRAINING SCHOOL

NAME OF FLIGHT TRAINING SCHOOL

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

LIMITS OF INDEMNITY AND PREMIUM

Please select Limit of Indemnity and Premium

SELECT NUMBER OF MONTHS

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.