Aviation questionnaire

This questionnaire relates to Civil Aviation. For Military Aviation please complete the Armed Forces Questionnaire.

Name Application number

Last 12 months Expected next 12 months

1. Please state hours flown as pilot, As pilot As As pilot As

aircrew or passenger (as applicable) in: or aircrew passenger or aircrew passenger

a) Company owned aeroplanes (used for business purposes)

b) Company owned helicopters (used for business purposes)

c) Privately owned aeroplanes (not company or club owned)

d) Privately owned helicopters (not company or club owned)

e) Club aircraft (as a club member)

f) Club aircraft (not as a club member)

g) Gliders (self launch)

h) Ballooning

i) Hang gliders

j) Microlights and powered hang gliders

2. Do you fly for any of the following purposes?
a) Sky diving Yes No
If Yes to any part, please
b) Airworthiness testing Yes No give details below including
a statement of hours usually
c) Experimental or prototype testing Yes No
flown per annum for the
relevant purpose(s)
d) Crop dusting Yes No

e) Air taxi operation Yes No

Total number of
3. Do you participate in jumps per annum

a) Parachuting Yes No

b) Skydiving Yes No

c) Base jumping Yes No

 4. For private or club fixed and rotary wing aviation please confirm your total solo flying experience, in hours?

5. Do you belong to any aviation club or association?  Yes No

If yes, please give details

6. If employed as pilot or aircrew, please confirm your employer holds a British Operators Certificate?

7. Please give details of licences held eg. private pilot, commercial pilot, student pilot, ATPL, night flying, radio telephony etc.

8. Do you participate in air shows, demonstrations, competitions or any record breaking attempts? Yes No
If yes, please give details

9. If your flying activities have not been illustrated through the above questions, please detail the activities here

Declaration
I declare that the answers I have given and the information I have provided in this questionnaire are true and complete
and, together with the information provided in the application, will be used by Zurich to assess whether and on what
terms to offer cover. I understand that if the answers I have given or the statements I have made are not true Zurich
may cancel the plan in which case no cover or other benefits will be provided. I have read and understood the Data
Protection declaration in the application and I consent to my personal data being used in the way described in the
Data Protection declaration and the Data Protection leaflet Your Privacy Is Important To Us.

Signature of Life to be Assured

Day Month Year

Date
NP113228A51 (07/14) RRD

Zurich Assurance Ltd. Registered in England and Wales under company number 02456671.
Registered Office: The Grange, Bishops Cleeve, Cheltenham, GL52 8XX.