General Aviation Insurance form Proposal form GA (en)General Aviation Insurance Form General Aviation Insurance FormPolicyholder:Name of the person who must appear on the insurance. Company name:First name:VAT number:Last name:Address:Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweEmail:Mobil nummer:Member of:- Select -AOPA/DMUDULFUDansk Svæveflyver UnionDansk Ballon UnionMembership number: Insurance renewal:An offer is usually valid for 1 month only.Insurance coverage:- Select -Liability insuranceLiability and hull insuranceGroundrisk all riskGroundrisk firePeriod from:Period to:The aircraft: Registration: Manufacturer: Model: Serial no.: Year of production:Max.Takeoff Weight (kilos): Aircraft / C of A:- Select -Factory built / StandardFactory built / ExperimentalHomebuiltHomebuilt test flightEngine type:- Select -PistonDieselTurbopropJetNumber of engines:- Select -12 Landing gear:- Select -Retractable GearFixed GearFixed Gear and SkisFixed with FloatsAmphibianAnnual Utilisation in hours: - Select -Not exceeding 100 hrsNot exceeding 200 hrsNot exceeding 300 hrsNot exceeding 400 hrsNot exceeding 500 hrsExceeding 500 hrsIs it hangered: - Select -YesNoHome base:Geographical limits:- Select -Europe excluding Greenland, Faroe Islands, Iceland and SvalbardEurope incl. Greenland, Faroe Islands, Iceland and SvalbardWorld wideWorld wide excluding America Hull value:Currency:- Select -EURUSDHull value:Hull deductible above 1%:Pilots / Passengers Named-/ Unnamed pilots:- Select -1 - named pilots2 - 6 named pilotsUnnamed pilots Min. License to category:- Select -LAPL / PPLPPLCPLPPL/IRCPL/IRATPLHour requirements for the pilot:- Select -Less than 100 hrsMin. 100 hrsMin. 200 hrsMin. 300 hrsMin. 400 hrsMin. 500 hrs No. of Crew:- Select -12no. of Pax.- Select -1234567891011121314151617181920>20Use(s) Commercial excl. Private / Pleasure Air freight Scenic flight Dealer- / demo flight Business Private and Pleasure LAPL/PPL schooling Training for higher certificate Parachuting Towing Competition flight Line inspection below 1000 ft AGL Aerobatic above 1500ft AGL Aerobatic below 1500ft AGL Photo flight above 1000 ft AGL Photo flight below 1000 ft AGL Other use:Claims history:If there have been any injuries within the last 5 years, they must be described. Any claims: Yes NoHow many clims:- Select -Ingen12345Describe the damage with: date of damage, which insurance (e.g. liability, comprehensive insurance), damage costs and what was damaged:Previous Contract:Named pilot(s):Name:Date of birth:Certificat- Select -LAPL / PPLPPLCPLPPL/IRCPL/IRATPL- Select -LAPL / PPLPPLCPLPPL/IRCPL/IRATPL- Select -LAPL / PPLPPLCPLPPL/IRCPL/IRATPL- Select -LAPL / PPLPPLCPLPPL/IRCPL/IRATPL- Select -LAPL / PPLPPLCPLPPL/IRCPL/IRATPL- Select -LAPL / PPLPPLCPLPPL/IRCPL/IRATPLPIC on model:PIC on type:PIC total:Notes for named pilots:Notes:Submit a Support! If you have any problems with the form, or would like us to fill it out, then give us a call. AGD ApS Jacob Severins Vej 26 9370 Hals TLF.: +45 22 23 06 87 e-mail: aviation@aviation.dk
