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RA-Aus Aircraft Declaration Membership Information

RA AUS Membership Name: ____________________________________________

Is the registered aircraft owner's name different to the RA Aus Membership name: YES NO

If yes, Registered Aircraft owners name: _____________________________________________

Address 1: _____________________________________________

Address 2: _____________________________________________

City: __________________________________________________

State, Postcode: ________________________________________

Contact phone: ________________________________________

Email: ________________________________________________

Would you like us to communicate with you electronically at the above email address: Yes

*** We will deliver your insurance policies, Product Disclosure Statements and our Financial Services Guide and other disclosure documents by sending an email with PDF attachments or sending an email with a hyperlink or sending a letter with our website or a combination of these options.

Aircraft Information

State: __________

Is the aircraft hangared: YES NO

Aircraft manufacturer: _______________

Aircraft model: ____________________

Is the aircraft homebuilt: YES NO

Are the aircraft's Airframe Hours under 50 hours: YES NO

Is the Aircraft a Weight-Shift-Control aircraft?: YES NO

Registration number: __________________

Engine type: _______________

PAX: PAX 1 Single Seat

Cover Type

Do you require aircraft hull insurance: YES NO

Type of cover required: Full Flight Risks Ground & Taxi Risks Ground Risks Only

Sum insured: $ ___________

Excess option: Standard(1% Hull Value, Min $500) $2,500 $5,000

Is the aircraft used for training: YES NO

If yes, Is the aircraft used for Ab-initio training of the insured only: YES NO

Is the aircraft used for Ab-initio training of third parties and/or Flying Schools: YES NO

Is the aircraft used for Mustering or Glider towing: YES NO

Is there any finance on the aircraft: YES NO

If yes, Name of Financier: ______________________________

Is the aircraft currently insured: YES NO

If Yes, Level of No Claim Bonus applied to your current policy:

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Not Applicable 1 Year 2 Years 3 or more Years

Name of current insurer: ________________

Current policy expiry date: _________

Inception date: ___________

Pilot Details

Name: _______________________________

Age: __________

Certificate type: Pilot Certificate Student Pilot Certificate

RA Aus membership number: _____________

Total flying time: Greater Than 100 Hours 100 Hours or Less

Has the pilot had any accidents, claims or breach of Air Navigational Regulations in past 5 years: YES NO

If you wish to add another pilot who has less than 100 hours flying time please provide their details in the space provided below.

Liability Cover

Liability Cover: $1,000,000 $2,000,000 $5,000,000 $10,000,000

Have you ever been refused this type of insurance, or had similar insurance cancelled, or had a renewal application declined, or had special term imposed: YES NO

Signature and Declaration

All answers and statements made in this document are correct and complete in every respect and no information has been withheld.

Applicant's Signature: __________________________________________

Date: _____________

Do you require Liability Insurance: YES NO

If required, please use the space below to provied details of any accidents, claims, breachs of Air Navigation Regulation, Insurnaces Cancelled, renewals declined, special terms imposed and Pilot with less than 100 hours total flying time: