HR Jennings Light Aircraft Insurance

Light Aircraft Insurance Quote Form

*required

1. PROPOSER:
*Forenames:
*Surname:
*Address :
*Postcode:
*Tel no. (home)
*Tel no. (business)
* Email address:

Are you a current member of LAA?	Yes No
AOPA?	Yes No

2. AIRCRAFT:

	Make:	Model:
	reg no.	Year of manufacture: (e.g. 2005)
	Hull value: £	Manufactured: or Homebuilt:
	Maximum take off weight:
	No. of passenger seats (ex. Pilot):	Estimated annual utilisation:

	Airfield where based:
	Hangared?	Yes No
	Is aircraft aerobatic?	Yes No
	If YES do you require cover for displays or competitions?	Yes No
	Do you require cover to be extended to include road transportation risks?	Yes No

3. LIABILITY COVER

Third party indemnity limit required:	£750,000 £1,000,000 £1,5000,000 Other £
Including legal liability to passengers?	Yes No
Do you require Crown indemnity?	Yes No

4. USES

Is ab initio instruction required? (If so, include pilot details under Question 5)	Yes No
Does your aircraft have a Public Transport Category C of A?	Yes No
Standard use provided is for private business and pleasure purposes only (Excluding use for hire and reward)
Please advise details of wider use if needed:

5. PILOTS

PILOT 1

Name:

Date of birth:

Day

Month

Year (e.g. 1980)

Hours logged: (fixed wing single engine piston)

Hours on insured aircraft: (see question 2)

Hours tailwheel:

Type of licence and ratings:*

* If N PPL licence, please advise details if full PPL A not available due to medical condition.

PILOT 2

Name:

Date of birth:

Day

Month

Year (e.g. 1980)

Hours logged: (fixed wing single engine piston)

Hours on insured aircraft: (see question 2)

Hours tailwheel:

Type of licence and ratings:*

* If N PPL licence, please advise details if full PPL A not available due to medical condition.

PILOT 3

Name:

Date of birth:

Day

Month

Year (e.g. 1980)

Hours logged: (fixed wing single engine piston)

Hours on insured aircraft: (see question 2)

Hours tailwheel:

Type of licence and ratings:*

* If N PPL licence, please advise details if full PPL A not available due to medical condition.

6. CLAIMS

Have any of the above pilots been involved in any accidents, loss or damage, whether claimed or not, involving an aircraft during the past 5 years?	Yes No

If YES, give date, description, amount of loss and insurer:

7. DECLARATION

I/WE declare that to the best of MY/OUR knowledge and belief the information provided in connection with this insurance is true and I/WE have not withheld any material facts. I/WE understand that non-disclosure or misrepresentation of a material fact will entitle the insurer to avoid this insurance.	*required

(A material fact is one likely to influence acceptance or assessment of this insurance by the insurers. If you are in any doubt as to whether a fact is material or not you should declare it.

© 2008 H R Jennings & Co Limited are authorised and regulated by the Financial Services Authority
Registered address: 21 Buckle Street, London E1 8NN