AVIATION INSURANCE PROPOSAL/KYC FORM-2

IMPORTANT

An Insurance Agent who assists an applicant to complete an application or proposal form for insurance shall be deemed to have done so as the agent of the applicant – Section 54 (2) Insurance Act 2003.Please answer ALL questions in full. Use CAPITAL LETTERS.

Combined Single Limit Required?Yes No

If Yes, State Limit of Indemnity: Per Event Per Year

Passenger Liability Required?Yes No

If Yes, Limit of Liability Per Passenger:

Third Party Liability Limit Required?Yes No

If Yes, Limit of Liability Per Person:
and Limit Per Period:

Baggage Liability Required?Yes No

If Yes, Limit of Liability Per Passenger:
and Limit Per Period:

Require Hull War Risk Cover?Yes No

If Yes, What Value:

Do you Require Personal Accident for Pilots?Yes No

Do you Require Loss of Life Benets for Pilots?Yes No

Period of Insurance:

From:

To:

COMPANY DETAILS

Date of Registration:

Incorporation No:

Nature of Business:

Name of Bankers:

Address of Bankers:

Name of Auditors:

Address of Auditors:

Names/Addresses of Company Directors:

Name 1:

Address:

Name 2:

Address:

PLEASE PROVIDE THE FOLLOWING: * Please provide photocopies and also bring along original copies of the documents for confirmation.

1) Certificate of Incorporation/Registration

2) Memorandum and Article of Association

3) Form CO2 Incorporation/Registration

4) Form CO7

5) Copy of authorization to operate from relevant regulatory bodies

DECLARATIONI/We, hereby declare that the above particulars and answers are true and complete in every respect, and that no information has been suppressed or withheld. I/We further declare that if such statements and particulars are in the writing of any person other than myself/ourselves such person shall be deemed to have been my/our agent for the purpose of ling the form.

Name of Proposer:

Signature:

Date:

Agent/Company Representative: