Seguro Aeronáutico

Name of insured *

Bussiness of Applicant *

Address *

DirecciónApartamento, piso, edificio (opcional)CiudadEstado / provincia / regiónCódigo postalPaís

Aircraft use is

Industrial AidCommercialMedevacPB+POther

Geographical Limits *

Anticipated utilisation

Hours per year *

Anticipated utilisation to/from USA

Hours per year *

Aircraft Base

Your Email *

Your Phone number *

Aircraft | Make and Model *

Aircraft Year *

Aircraft Reg. N° *

Setting Capacity | Crew *

Setting Capacity | Pass *

Physical Damage Agreed Value *

Provide figure in US Dollar *

Third Party Bodily injury &/or Property damage (exel ocupants)Passenger Bodily injury liabilitySingle limit including passengersPersonal accident - CrewPersonal accident - Passengers

Name *

Age *

Total Hours

Multi-Engine Hours *

Turboprop Hours *

Jet Hours *

Make and model hours *

Hours in last 12 months *

Pilot training | (Give details of type + frecuency of recurrent training) *

Claims history for past 5 years - Include date of loss, description and amount of claim for the pilots and applicant *

NON-DISCLOSURE CLAUSE You must ensure that you are complying with your duty of disclosure of all material matters and particularly that you satisfy yourseself as to accuracy and completeness of the information you provide to insurers. In this respect you must provide all information whether favourable or not, which might influence the judgement of a prudent Insurer in determining whether he will take the risk and if so, for what premium and on terms. Failure to observe this obligation could void and contract entered into from inception and could lead to claims not being met

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AIRCRAFT

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OTHER INFORMATION

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