Escolar Documentos
Profissional Documentos
Cultura Documentos
1. DETAILS OF INSURED
(a) Named Insured
(list all owners/
operators)
(c) Address of
Insured
(d) Business A/H Fax Number
Telephone Telephone
(e) Policy Number Expiry Date Claim
Number
(f) Are you registered for GST? If Yes, to what extent (%)
are you entitled to claim an Input Tax Credit on your Yes No __________________ %
premium?
ABN:________________________________
What is your Australian Business Number (ABN) (if
applicable)?
2. PARTICULARS OF ACCIDENT
(a) Date of Accident Time of Accident a.m./p.m.
(b) Site/Location of
Accident
(g) Passenger
Names
(h) Injuries
(j) Please provide details of ACCIDENT in the box below (if more space is required, please attach a
separate sheet of paper):
(k) Please provide details of AIRCRAFT DAMAGE in the box below (if more space is required, please
attach a separate sheet of paper):
(o) Give names, addresses and telephone numbers of all witnesses of the accident in the box below
(p) Please provide details regarding the cause of the accident in box below:
(q) Was the aircraft operated in accordance with CAR’s and CAO’s?
Yes No
(r) In your opinion, was the accident caused or contributed to by the
Yes No
actions or negligence of any party or persons?
If “Yes”, please provide a full description in box below:
3. PILOT DETAILS
(a) Licence No Licence Last Medical / /
Type
(b) Total Hours Hours on Hours in last 90
Type days
(c) FIXED WING Hours FIXED WING Hours
Piston Turbine
(d) HELICOPTER Hours HELICOPTER Hours
Piston Turbine
4. AIRCRAFT DETAILS
DOCUMENT NUMBER ISSUE DATE EXPIRY DATE
(a) Maintenance Release:
ENGINE ID SERIAL NUMBER SINCE NEW (Hrs) SINCE O/H (Hrs) TO RUN TO O/H
(h) Left/Front
(i) Right
PROPELLOR ID SERIAL NUMBER SINCE NEW (Hrs) SINCE O/H (Hrs) TO RUN TO O/H
(k) Left/Front
(l) Right
5. OTHER INFORMATION
Are there any other disclosures you wish to make in connection with this
Yes No
matter?
If “Yes”, please provide details in the box below:
6. NOTES
1. It is important that no removal of, or repairs to, the aircraft be made or authorised (except to
ensure the safety of the aircraft) without prior notification to Insurers and/or surveyors acting on
behalf of insurers. Following notification and approval of the foregoing IT REMAINS THE
RESPONSIBILITY OF THE INSURED TO AUTHORISE REMOVAL AND/OR REPAIRS.
2. If this form is to be signed by an Agent of the Insured, an appropriate Letter of Authority should
be attached hereto.
DECLARATION BY INSURED
NAME OF INSURED/AGENT
..........................................................................
AGENT'S ADDRESS
..........................................................................
SIGNATURE
..........................................................................
DATE ………………………………………………..