Pilot Insurance Group

In order for us to give you an accurate quote please complete all of the following information.

If you prefer not to fill out this form you can email us. We value your privacy. Please read our Privacy Statement.

Step 1 - Pilot Information

*Pilot Status or Certificate
Non-Pilots choose "I am not a Pilot"
and skip to Step 2

Ratings
Instrument
CFI
Seaplane
Helicopter
Multi Engine
Glider

Please enter whole numbers only
*Total Time	Hours flown in the Past 12 Months
Estimated Flight Hours for Next 12 Months
In the past 3 years, have you flown: (Please check all that apply) Primary Instruction of Students No Primary Instruction but other CFI work Aerobatic Aircraft Agriculture Aircraft Air Ambulance Experimental and/or Homebuilt Offshore Helicopter Ultralight Aircraft *For some of the above aviation activities you will be asked to provide your current annual hours of the activity and/or type of aircraft.

What company do you work for?

Which type of plane do you fly?
charter plane
passenger plane
other

Where do you fly to?
within Australia
other countries

What sort of surface do you land on?
tarmac
grass airstrip
water
other

Step 2 - Policy Information

*Policy Amount Requested

Step 3 - Personal Information

*First Name

M.I.

*Last Name

*Email
Please be certain your email address is correct. We will send you via email
a link to your own private web page with your quote information. Your quotes
will be prepared and sent to you by the next business day.

Address

City

*State

Postcode

Work Phone	Home Phone
*Sex Male Female
*Date of Birth
*Height cm	*Weight Kg

Step 4 - Your Health

*Have you ever had a health condition that would affect the underwriting of this policy?
No Yes

*Do you take any prescription Medications?
No Yes

*Do you use any tobacco or nicotine products?
No
Yes

*Has there been any occurrence of cardiovascular disease or cancer before the age of 60 in natural parents or siblings?
No Yes

How did you find the Pilot Insurance Group?

Any Additional Comments?

The advice to be provided to you by answering the questions above will
be based on a limited set of information. Because of that you should,
before acting on the advice, consider the appropriateness of the advice
having regard to your relevant personal circumstances.

If you require a more comprehensive risk plan then please arrange for an
interview by contacting Pilots Insurance Group on (02) 8425 7814

This information will not be the final determining factor in your eligibly for insurance.