Application for HDI Loss of Licence Insurance

Proposal Form

Aircrew Care Individual Loss of Licence Insurance

Proposal Form 07/2024

Fair Processing Notice This Privacy Notice describes how we / HDI Global Specialty SE collect and use the personal information of insureds, claimants and other parties (for the purpose of this notice “you”) when we are providing our insurance and reinsurance services. collect and use the personal information of insureds, claimants and other parties (for the purpose of this notice “you”) when we are providing our insurance and reinsurance services. The information provided to the Insurer, together with medical and any other information obtained from you or from other parties about you in connection with this policy, will be used by the Insurer for the purposes of determining your application, the operation of insurance (which includes the process of underwriting, administration, claims management, analytics relevant to insurance, rehabilitation and customer concerns handling) and fraud prevention and detection. We may be required by law to collect certain personal information about you, or as a consequence of any contractual relationship we have with you. Failure to provide this information may prevent or delay the fulfilment of these obligations. Information will be shared by the Insurer for these purposes with group companies and third party insurers, reinsurers, insurance intermediaries and service providers. Such parties may become data controllers in respect of your personal information. Because we operate as part of a global business, we may transfer your personal information outside the European Economic Area for these purposes. You have certain rights regarding your personal information, subject to local law. These include the rights to request access, rectification, erasure, restriction, objection and receipt of your personal information in a usable electronic format and to transmit it to a third party (right to portability). If you have questions or concerns regarding the way in which your personal information has been used, please contact: info@aircrewcare.com. We are committed to working with you to obtain a fair resolution of any complaint or concern about privacy. If, however, you believe that we have not been able to assist with your complaint or concern, you have the right to make a complaint to the Bundesanstalt für Finanzdienstleistungsaufsicht (BaFin) Sektor Versicherungsaufsicht Grauheindorfer Str. 108 D-53117 Bonn E-mail: poststelle@bafin.de. For more information about how we process your personal information, please see our full privacy notice at: https://www.hdi-specialty.com/int/en/legals/privacy, www.aircrewcare.com, https://jurkowitsch.eu/en/privacy-policy/.

POLICY HOLDER: Paul Bus t/a AircrewCare, Het Poortgebouw, Beech Avenue 54-62, Schiphol, 1119 PW.

You must take care in answering all the following questions which are relevant to us in providing this insurance and setting the terms and premium. Please contact us if you do not understand the question or the nature of the information required or please seek guidance from your broker. Failure to provide information or the provision of incomplete or inaccurate information may result in the loss of cover or other remedies. You must tell us as soon as practicably possible about any changes to the information you have provided to us which happens before or during any period of insurance. We will tell you if such change affects your insurance and if so, whether the change will result in revised terms and/or premium being applied to your policy. If you do not inform us about a change it may affect any claim you make or could result in your insurance being invalid.

Name

Title or RankFirst name(s)Surname

Date of birth

Date

Nationality

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Mobile Number

Email

example@example.com

Gender (Please tick)

Flying Licences Held (List all types (CPL,ATPL etc) Country of issue and Numbers)

Employer

Type Rated

Application Type: (please tick)

Currency

Annual Salary

Occupation Type: (Please tick)

*Employer pays your tax and national insurance Self-Employed

**Employer does not pay your tax and national insurance. You pay this yourself

APPLICATION DETAILS:

Sum Insured

Would you like to add temporary benefit (TTD) cover? (Please tick)

2% of the Lump Sum amount for a maximum of 24 months

Would you like to add psychological benefit?

Which payment frequency do you prefer?

Have you ever been grounded or had a licence invalidated for medical reasons?

Has any limitation ever been endorsed of any of your licenses?

Has any insurance company or underwriter declined or deferred a proposal from you?

Has any insurance company or underwriter charged or quoted more than standard rates?

Has any insurance company or underwriter imposed an exclusion or waiver on your insurance cover?

Has any insurance company or underwriter cancelled or declined to renew your insurance?

If you have answered Yes to any of the above, please give full details below:

Are you entitled to any other loss of licence insurance arranged by you, your association or your employer?

If Yes, please provide details: (sum insured, multiples of salary etc.)

Please give the date of your last electrocardiograph examination approved by your licence issuing authority:

Date

Month

Year

Were you advised of any abnormality revealed by this or any previous examination?

If you have answered Yes to any of the above, please give full details below:

Please state:

Your height (cms)

Your Present weight (kilos)

Your weight 12 months ago (kilos)

Have you ever suffered from any conditions or illnesses which necessitated hospital attendance, admission, diagnosis or treatment?

If you have answered yes to the above, please give full details below:

After or during a medical examination have you ever been required to take additional tests?

After or during a medical examination have you ever been referred for specialist examination?

After or during a medical examination have you ever had the issue or renewal of your medical certificate deferred?

After or during a medical examination have you ever had to return for examination at less than the normal interval?

After or during a medical examination have you ever been ordered to take drugs or follow any special diet?

1. Last physical examination carried out from / at

2. Have you ever suffered or do you currently suffer from any of the following illnesses:

2.1 Gout, diabetic diseases or other metabolic diseases?

2.2. Infectious diseases (e.g. hepatitis, diseases of the genitals, tuberculosis etc.)?

2.3 Diseases of the heart, blood vessels, circulation (blood pressure)?

2.4 Diseases of the respiratory, digestion system (gullet, gastric, intestine, liver, pancreas etc.), kidney?

2.5 Diseases of the musculoskeletal system as e.g. muscles, bones, joints, ligaments (attrition of the backbone, curvature, spinal disc, lumbago, rheumatism etc.)?

2.6 Diseases of the eyes, ears, nose/ air sinus, throat, disturbance of equilibrium (vertigo, pressurisation disorders etc.)?

Spectacle wearer?

Dioptre

Adjacency (Left)

Adjacency (Right)

Distance (Left)

Distance (Right)

2.7 Diseases of the genitals?

2.8 Other, not above mentioned diseases?

2.9 Have you had any injuries or accidents where you have consulted a medical doctor?

2.10 Have you ever received medical treatment in a hospital in the last five years or intend to or advised to? What for? Do you take up any medicaments? If so, which?

2.11 Mental disorders (e.g. depression, schizophrenia, fear of flying, neuroses, psycho vegetative or psychosomatic disease, nervousness or other)?

2.12 Strokes or blackouts, reduced consciousness, cramps (epileptic seizures)?

If you have answered above questions 2.1 to 2.12 with Yes, we need additional information: Type and course of the illness / accident, cured? What is the result of the examination? When, how often, how long? Which doctors or hospitals can provide us with some information (contact details please). (If the spare is not sufficient, please attach additional pages.)

3. Was an operation or hospital stay or therapy carried out / or is planned?

If you have answered above question with Yes, we need additional information: Type and course of the illness / accident, cured? What is the result of the examination? When, how often, how long? Which doctors or hospitals can provide us with some information (contact details please).

Any other Information We should know about

I/we declare that the information disclosed in this proposal, is to the best of my/our knowledge and belief both accurate and complete. I/we have taken care not to make any misrepresentation in the disclosure of this information and understand that all information provided is relevant to the acceptance and assessment of this insurance, the terms on which it is accepted and the premium charged.

Language Requirement for Documentation: All medical and other relevant documentation submitted to the insurer must be provided in English. This requirement applies to documents related to claims, underwriting, and any other procedures necessitated by this policy. In instances where the original documents are not in English, the insured is obligated to furnish certified translations of the documents provided by a sworn and court-certified translator - including a copy of the original documents. This is essential for the accurate and efficient processing of documents and ensuring compliance with the terms of this policy.

Signature of proposer(s)

Date

Signing this proposal does not bind you to enter into this insurance. We and you are entitled to choose the law that will govern this contract of insurance. We propose Dutch law and this will apply unless otherwise agreed. No cover is in force until this proposal is accepted by the insurer and the premium is paid. The insurer reserves the right to decline any insurance proposal or to offer different premium and terms from those quoted dependent on the information you have provided.