You are on page 1of 4

AVIATION – ACCIDENT CLAIM FORM

1. DETAILS OF INSURED
(a) Named Insured
(list all owners/
operators)

(b) Aircraft Type Registration

(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

(c) Nature of Flight


(eg Private,
Charter etc)

(d) Stage of Flight or


Operation

(e) Pilot Name Telephone Fax

(f) Pilot Address

(g) Passenger
Names

(h) Injuries

(i) All-up Weight at Maximum Permitted


Time of Accident All-up Weight

(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):

(l) Please complete the following (as applicable):

Strip Length Alignment Surface

Level/Incline Wet/Dry ALA/PVTE/AG

Wind Direction Wind Strength Visibility

Ambient Temperature Cloud

(m) Was there any third party injury?


Yes No
If “Yes”, please provide details in box below:

(n) Was there any third party property damage?


Yes No
If “Yes”, please provide details in box below:

(o) Give names, addresses and telephone numbers of all witnesses of the accident in the box below

Name Address Contact Numbers


1.
2.
3.
4.

(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

(e) Type Endorsement? Date Given / /


Yes No
(f) Last Annual Review Date: / / By Whom

(g) AGRICULTURAL AGRICULTURAL


HOURS Helicopter HOURS Fixed Wing

(h) Ag Rating 1 Ag Rating 2 Hours since 1.


Yes No Yes No
issue 2.
(i) Other
Endorsements

4. AIRCRAFT DETAILS
DOCUMENT NUMBER ISSUE DATE EXPIRY DATE
(a) Maintenance Release:

(b) Certificate of A/C Reg:

(c) Maintenance Release Issued by:

(d) M/R Hours Since Issue:

(e) Aircraft Type/Model: Serial No:

(f) Total Time on Airframe: Major Inspection Due


(If applic):
(g) Engine Type/Model: TBO:

ENGINE ID SERIAL NUMBER SINCE NEW (Hrs) SINCE O/H (Hrs) TO RUN TO O/H
(h) Left/Front

(i) Right

(j) Propellors Type/Model: TBO:

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

I/WE HEREBY DECLARE THE FOREGOING PARTICULARS PROVIDED ON THE


PAGES OF THIS FORM TO BE TRUE IN EVERY RESPECT AND THAT NO
INFORMATION HAS BEEN EXAGGERATED, OMITTED OR WITHHELD, AND
THAT THE LOSS/DAMAGE CLAIMED REPRESENTS THE LOSS/DAMAGE I/WE
ARE ENTITLED TO CLAIM IN TERMS OF THE POLICY AND THE INSTRUCTIONS
CONTAINED THEREIN. I/WE ACKNOWLEDGE THAT THE INSURER MAY GIVE
TO, AND OBTAIN FROM, OTHER INSURERS AND/OR INSURANCE REFERENCE
SERVICES, PERSONAL INFORMATION AS WELL AS INSURANCE CLAIMS
INFORMATION OBTAINED DURING THE COURSE OF THE INSURANCE
CONTRACT.

NAME OF INSURED/AGENT
..........................................................................

AGENT'S ADDRESS
..........................................................................

SIGNATURE
..........................................................................

DATE ………………………………………………..