Please advise the aircraft registration of

For the Attention of:

aircraft applicable:
Mandy Ramogayane
ZS-MKO

Aviation Insurance

PILOT QUESTIONNAIRE

IMPORTANT ADVICE TO ALL PROPOSERS

The information called for in this Questionnaire is required for insurance purposes only and will be treated
accordingly. However, it is important that all questions are answered accurately and truthfully as non-disclosure or
misrepresentation may prejudice future insurance claims. Do not omit any details because you think, or your advisors
(professional or otherwise) tell you that they are irrelevant or immaterial.

PERSONAL PARTICULARS
Surname Pretorius First Name Corné
Postal Address P. O. Box 85, Brits, 0250
Occupation Pilot
Telephone Number (W) Email address bushpilotzaa@hotmail.com

Mobile Number 082 846 9487 Facsimile Number

Telephone Number (H) Date of Birth 1973-04-16

FLYING LICENSE DETAILS

Type of License CPL (A) License Number 0270253693

Date of Issue 1999-09-06 Expiry Date 30-11-2020
Restrictions None Instrument rating YES X NO
Instructors rating (e.g. Grade
Test Pilot rating (e.g. Class 1)
1) Grade II
Instrument safety pilot
Night rating YES X NO YES NO X
rating
Tug pilot rating YES NO X Other (Specify)

LOGGED FLYING EXPERIENCE IN RESPECT OF CONVENTIONAL, POWERED AIRCRAFT

(Excluding microlight / ultralight and gliders)
Fixedwing Aircraft Rotorwing Aircraft
As PIC Dual As Co-Pilot As PIC Dual As Co-Pilot

Single-Piston 3246 227

Multi-Piston 16
Single-Turbine/Turboprop 74 4:50 107
Multi-Turbine/Turboprop

Jet Engine

TOTAL 3320
GRAND TOTAL 3683
FIXEDWING ROTORWING

DJA Aviation (Pty) Ltd

Reg. No. 1971/000601/07. An Authorised Financial Services Provider (FSP No.15808)
Building 8, Parc Nicol Office Park, 3001 William Nicol Drive, Bryanston, 2191, South Africa
P O Box 71626, Bryanston, 2021 • Telephone: +27 11 463 5550 • Telefax: +27 11 463 5551
Directors: D.A. Fisher, M.P. Gill, J. Herman, C Kirstein, J.I. Nieuwoudt, G.J. Speller (British), L.B. Williams
 LOGGED FLYING EXPERIENCE IN RESPECT OF MICROLIGHTS / ULTRALIGHTS AND GLIDERS (not to be
included in the above experience declaration)
Microlight / Ultralight Glider Powered Glider
As PIC Dual As PIC Dual As PIC Dual
3-Axis
Weight Shift
Gyrocopter
Grand Total

LOGGED FLYING EXPERIENCE BY TYPE STARTING WITH The AIRCRAFT TYPE/S RELEVANT TO THIS
APPLICATION
Hours flown in
Make & Model As PIC Dual As Co-Pilot Grand Total the past 12
months
C210 39:15 5:55 45 38:15

If the list is particularly extensive, you need only specify types that you have flown in the past 12 months and types that
you anticipate flying in the next 12 months. Preferably, however, specify all types, using a separate sheet if necessary.

PREVIOUS ACCIDENT HISTORY

Please give details below of any accident involving any aircraft in which you were acting as Pilot-in-Command or
Co-Pilot, or whilst you were flying Dual, including whilst you were under (or giving) instruction, during the 60 months
immediately proceeding the current date. Give the following details for each separate accident, using a separate sheet if
necessary.

Date of Accident N/A Owner of Aircraft N/A

Aircraft Make, Model & Reg
N/A Purpose of Use N/A
No
Extent of Damage N/A Cost of Repairs (if known) N/A
Official cause of accident, or your opinion of probable cause N/A
if no official finding was made at the time or subsequently

OTHER INFORMATION
Please specify any other information that you believe Insurers should be aware of in relation to your flying experience or
flying ability (such as military or non-powered flying experience, flying awards received, etc.) taking into account the
Warning on the first page of this Questionnaire and the following Declaration.
N/A

Declaration
I hereby declare that, to the best of my knowledge and belief, the particulars and answers contained in this Questionnaire
are true, complete and correct and that I have not withheld any information that I believe would change a reasonable
person’s opinion of my flying experience or flying ability.
ZS-MKO
AIRCRAFT REGISTRATION NO: ………………………………………………………………………………………

Signature:………………………………………………………………. 05-12-2019
Date: ………………………………………………..

Please return this Questionnaire to DJA Aviation at:

Building 8, Parc Nichol, 3001 William Nicol Drive, Bryanston, 2021, South Africa. P O Box 71626,
Bryanston, 2021* Facsimile Number: +27 (0) 11 463-5551 * E-mail: mail@dja-aviation.co.za