AVIATION QUESTIONNAIRE

*(Strike out whichever is not applicable)

Name:
Contract No:

1. Pilot license currently held: Student Private Commercial VFR IFR

2. Date of issue: ____________________

3. Schedule Of Flying Time Flight Hours

Type of Flying Aircraft Number Last 12 1 to 2 years Estimate next

Type of months ago 12 months
Engines
Civilian (Non-commercial)
Pleasure only
Personal business

Aerobatics,Racing,Stunting

Civilian(Commercial)
Scheduled Airline
Non-Scheduled Airline

Corporate Flying

Instructing

Crop Dusting or Seeding

Firefighting

Advertising ,
Mapping,Surveying or
Patrolling
Other(specify)
Military Flying
Purpose/Type/Branch:
Duties:

4. Do you fly into remote areas? No Yes

If “Yes”, specify areas:__________________________________

5. Total number of hours flown as a pilot: _________________ Date of last flight: ______________

6. Have you ever been involved in an aircraft accident? No Yes

If “Yes”, give details:____________________________________

7. Have you ever been grounded or had your licence revoked? No Yes
If “Yes”, give details:____________________________________

8. Additional remarks:

I declare that the answers to the above questions are true and complete and shall form part of an
Application with Reliance Life Insurance Insurance Company for insurance on my life.

Date : _________________
Signature of Life Insured : _______________________

UW/AviationQ/Ver.1.4/28th Dec 2010

UW/AviationQ/Ver.1.4/28th Dec 2010