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Aviation Questionnaire

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Aviation Questionnaire

Aviation Questionnaire

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Life Insured's Name*

First Last

Agent's Name*

First Last

1. What type of Pilot’s license do you currently hold*

i. Total number of hours flown*

ii. Date of last flight as pilot*

MM slash DD slash YYYY

iii. Date of last license renewal*

MM slash DD slash YYYY

2. Indicate flying time below (as pilot, student pilot, air crew member or passenger):

Tick, whichever is appropriate

Scheduled airlines

Type of Aircraft*

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Nonscheduled air carriers (Give name)

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12 24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Employer owned planes

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Crop Dusting

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Water Bombing

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Mapping

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Pipeline inspection

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Advertising

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Photography

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Flight Instructor

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Private (other than above)

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Military

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Test /Experimental

Type of Aircraft

Past 12 months (No. of hrs.)

Past 12-24 months (No. of hrs.)

Contemplated Next 12 months (No. of hrs.)

Other (Explain)

3. Purpose of Flying*

Pleasure

Business

Commercial

Military

Other

If Other, explain

4. Have you ever been grounded, fined or reprimanded for violation of Air Regulations?

Yes

No

IF Yes, state:

Nature of Violation:

Date of Violation

MM slash DD slash YYYY

5. Have you ever been involved in any accidents associated with flying?*

Yes

No

6. Do you expect to be engaged in any of the following?

Freight transport*

No

Yes

Survey & Patrol*

No

Yes

Student instruction*

No

Yes

Crop dusting*

No

Yes

Testing*

No

Yes

Taxi flying*

No

Yes

Stunt Flying*

No

Yes

Photography*

No

Yes

Exhibition Flying*

No

Yes

If other, please specify:

7. Please provide any additional information below*

I hereby declare that the above information is true and complete and shall form part of my application to the Company.

Signature of Life to be Insured*

Signature of Life to be Insured

Date*

MM slash DD slash YYYY

Date

Witness*

Witness

Date*

MM slash DD slash YYYY

Date

Δ

Main Office: 4th Floor Gordon House, 1 Coney Drive
P.O. Box 1762, Belize City, Belize C.A.

Cayo Office: 31 Guadalupe street, San Ignacio

Orange Walk Office:
23 Belize Corozal Road, Orange Walk Town

Corozal Office:
4 Park Street North, Corozal Town

221-5143
671-5143
info@rfglife.com

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