Basic Information

Required fields are marked with an asterisk *

Title

First Name

Last Name

Date of birth

Are you a pilot/trainee pilot?

Email address

Phone number (with int. phone code)

Employer's name

Employer's nationality

Gross annual salary in Euro

Training centre's name

Training centre's nationality

Desired inception date

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Choose your Coverage

Death/TILA desired sum insured

Permanent loss of licence

YES NO

Temporary unfitness

YES NO

Excess period Temporary unfitness

Option A : Non-deduction of the daily allowances *

Option B : Deduction of the daily allowances *

Deduction of the daily allowances paid by the Representative from the Permanent loss of licence capital. When the definitive withdrawal of medical fitness or authorisation to work as flight crew occurs after a state of Temporary Unfitness, for a same cause, illness or Accident as that which caused the Permanent loss of licence, the capital amount to be paid shall

Monthly Premium : 0?

Including xx? of taxes and xx ? of association fees

You don't know which coverage to choose? You will find hereunder the level of coverage usually chosen by our insured.

Basic

Death/TILA
desired sum insured

1 x gross annual salary

Permanent
loss of licence

2 x gross annual salary

Price Estimation

/month

Advanced

Death/TILA
desired sum insured

2 x gross annual salary

Permanent
loss of licence

3 x gross annual salary

Price Estimation

/month

Premium

Death/TILA
desired sum insured

3 x gross annual salary

Permanent
loss of licence

3 x gross annual salary

Temporary unfitness

60% of annual salary
Excess period : 60 days

Price Estimation

/month

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Complementary information

Required fields are marked with an asterisk *

Address

Address line 2

Zip Code

City

Country

Nationality

Last class 1 renewal date

Place of birth (city)

Place of birth (country)

Contract type

Since

Contract end time

Job title

Other

Training start date

Training end date

Type of training

Desired Premium payment frequency

Upload your ID (supported format : pdf, png, jpg)

Browse

Upload your medical fitness (supported format : pdf, png, jpg)

Browse

I acknowledge having read and accepted the provisions of the information notice of the PILOT SAAM contact No. : A 5045.0001, downloadable here

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Health questionnaire

Insured

- Marital status ? *

- Profession ? *

- Working part-time ?*

YES NO

- If yes, is it for medical reason ?

YES NO

- If yes, activity rate (%) ?

1a. Height (cms) ? *

1b. Weight (kgs) ? *

Further Information

2. Since obtaining your Licence, have you had one or many:

Suspension for medical fitness? *

YES NO
Specific exemption? *

YES NO
Validity limitation? *

YES NO

- if yes, reason, date and duration

3. Are you currently/have been off work over the past 5 years for more than 3 weeks *

YES NO

- if yes, reason, date and duration

4. Are you currently? or have you been over the past 5 years? on a diet, under strict medical control or taking medication for more than 30 consecutive days ? *

YES NO

- if yes, please precise reason, date and duration

5. Over the past 5 years, have you stayed in a medical institution? (clinic, nursing home, wellness center, psychiatric service) *

YES NO

if yes, please precise reason, date and duration

6. Over the past 5 years, have you undergone a surgical intervention (except appendicitis and tonsils) *

YES NO

- if yes, please precise reason, date and duration

7. To your knowledge, are you to undergone a surgical intervention, take medical examination or consult a doctor in the next 3 months? *

YES NO

- if yes, please precise reason, date and duration

8. Did any medical exam you have taken over the past 3 years (blood test, x-rays, urine, scans) highlight anomalies? *

YES NO

- if yes, please precise reason, date and duration

Futher Information

2. Are you currently/have been off work over the past 5 years for more than 3 weeks *

YES NO

- if yes, please precise reason, date and duration

3. Are you currently? or have you been over the past 5 years? on a diet, under strict medical control or taking medication for more than 30 consecutive days ? *

YES NO

- if yes, please precise reason, date and duration

4. Over the past 5 years, have you stayed in a medical institution? (clinic, nursing home, wellness center, psychiatric service) *

YES NO

if yes, please precise reason, date and duration

5. Over the past 5 years, have you undergone a surgical intervention (except appendicitis and tonsils) *

YES NO

- if yes, please precise reason, date and duration

6. To your knowledge, are you to undergone a surgical intervention, take medical examination or consult a doctor in the next 3 months? *

YES NO

- if yes, please precise reason, date and duration

- Working part-time ?*

YES NO

- If yes, is it for medical reason ?

YES NO

- If yes, activity rate (%) ?

- Are you in a service activity witout reduction of hours for health reasons ? *

YES NO

- if NO, what is the medical reson for being off work ?

- What medical fitness certificate do you hold ? *

- Indicate the licence authorising your job

- Is it a European licence *

YES NO

- Indicate, as applicable, what licence it is, as well as any other licences held

- Before your admission, were you refused by an aeromedical centre (CEMPN in France) ? *

YES NO

- if Yes, give the reason

- if Yes, date

- if Yes, aeromedical centre address

A. Are you currently insured or have you already been covered for permanent loss of licence ? *

YES NO

- if Yes, sum insured for permanent loss of licence

- if Yes, insurance company ?

- if Yes, reason of cessation ?

- if Yes, date of cessation ?

- or accepted for the risk with a surcharge, adjourned or with exclusion ? *

YES NO

- if Yes, date

- if Yes, reason

B. Do you receive an invalidity allowance ? *

YES NO

- if yes, illness category ?

- if yes, illness since ?

- if yes, military category ?

- if yes, military since ?

- if yes, worplace accident category ?

- if yes, worplace accident since ?

- invalidity reason

1- Have you had, Since obtainning your licence

A. One or several suspensions of medical fitness by an aeromedical centre ? *

YES NO

- if yes, reason

- date

- address of this aeromedical centre

B. One or several special derogations ? *

YES NO

- if yes, reason

- date

- address of this aeromedical centre

C. one or several validity limitations ? *

YES NO

- if yes, reason

- date

- address of this aeromedical centre

2- Have you been off work for accident/illness? (including thermal cures)

- Have you been off work for accident/illness (including thermal cures) *

YES NO

A. if yes, reason date and duration of 30 days and more time offer over the last 3 years

B. if yes, reason date and duration of less than 30 days time offer over the last 12 months

3- Have you suffered from, or have been treated for, or do you currently suffer from

A. Spinal problems?

- Spinal problems - Lumbago *

YES NO

- Spinal problems - vertebral compression *

YES NO

- Spinal problems - osteoarthritis *

YES NO

- Spinal problems - Neck pain *

YES NO

- Spinal problems - Sciatica *

YES NO

- Spinal problems - Discal hernia *

YES NO

- Spinal problems - Osteoporosis *

YES NO

- Spinal problems - Scoliosis *

YES NO

- Other(s) (specifiy) ?

- if yes, reports and dates of x-rays taken

B. Joint infections ? *

YES NO

- if yes, which one(s)

C. Problems with your digestive system? *

YES NO

- if yes, which one(s)

- Dates and results of laboratory examinations and x-rays taken

D. Cardiovascular problems? *

YES NO

- if yes, which one(s)

E. Date of last electrocardiogram *

- Results *

F. Problems with your respiratory system? *

YES NO

- if yes, which one(s)

G. ENT problems? *

YES NO

- if yes, reason

- n° of days

- date

- if yes, reason

- n° of days

- date

- if yes, reason

- n° of days

- date

H. Hearing problems? *

YES NO

- In the case of an audiogram indicating a problem, date and result of the last one

I. Vision problems? *

YES NO

- if yes, which one(s)

- do you use corrective glasses or lenses? *

YES NO

- Vision before correction RE

- Vision before correction LE

- Vision after correction RE

- Vision after correction LE

J. From?

- From nervous depression *

YES NO

- From mental problems *

YES NO

- From neuro vegetative problems *

YES NO

- From anxiety *

YES NO

- From asthenia *

YES NO

- From insomnia *

YES NO

- From spasmophilia *

YES NO

- if yes, date

- treatment

K. Hormonal problems? *

YES NO

- if yes, date

- nature of investigations

- treatment

- operation report

L. Genital or urinary system problems? *

YES NO

- if yes, date

- treatment

4- Different laboratory examinations (carried out to date have given the following results):

- blood count normal? *

YES NO

- Leukocyte formula normal? *

YES NO

- Platelet count normal? *

YES NO

- Urea normal? *

YES NO

- Triglycerides normal? *

YES NO

- Uric acid normal? *

YES NO

- Creatinine normal? *

YES NO

- Glucose normal? *

YES NO

- Gamma GT normal? *

YES NO

- Cholesterol normal? *

YES NO

- Transaminase normal? *

YES NO

5- What are:

- What is your blood pressure? *

- What are your habits (daily consumption) concerning tobbacco? *

- What are your habits (daily consumption) concerning alcohol? *

- Have you undergone one or several surgical interventions ? *

YES NO

- if yes, date(s) and reason(s)

- To your knowledge, are you to undergo a surgical intervention within the next 3 months *

YES NO

- if yes, which one(s)

- reason

6- Are you currently under medical supervision or undergoing any specific treatment? *

YES NO

- if yes, which one(s)

7- Have you suffered from, or are currently suffering from problems other than those mentioned? *

YES NO

- if yes, which one(s)

- Place of signature *

- Date of signature *

I certify that I have accurately and honestly answered the questions in this medical questionnaire, and know that any omission or inaccurate declaration, as well as the withholding of information or intentional false declaration by me may cause, respectively, a proposed adjustment to tariffs or cancellation of subscription pursuant to articles L. 113-8 and L. 113-9 of the French Insurance Code.

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Beneficiary clause

Required fields are marked with an asterisk *

Option 1 - Contractual Clause

Option 2 - Specific designation

Option 3 - Banking Designation

I designate as beneficiary(ies) of the death/TILA capital:

For the outstanding balance due, the balance paid to:

First Name

Last Name

Birth Name

Zip Code of birth

City of birth

Country of birth

Date of birth

Allocated capital in %

Address of residence

Zip code

City of residence

Country of residence

Failing this, the heirs of the subscriber in order of succession.

INDICATE: first name, last name, maiden name, date and place of birth (zip code, city and country), address of main residence and distribution percentage if there are several beneficiaries.

When a specified beneficiary accepts the benefit of the contract under the conditions set out in regulations in force, its designation becomes irrevocable (article L.132-9 of the Insurance Code).

Warning - Acceptance must be made according to one of the following two methods: either through an amendment signed by the insurer, the subscriber and the beneficiary, or by a deed or private agreement signed solely by the subscriber and the beneficiary, but this second method only has any effect on the insurer when it has been notified thereof.

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Submit

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Premium payment

Yearly amount :

Premium due for the next period (from to ) :

Please choose your premium payment method :

Direct debit

Virement

Bank transfer

IBAN

BIC

Bank account owner

Bank domiciliation

IBAN : FR76 3006 6109 7200 0105 7660 158
BIC : CMCIFRPPCOR

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Signature

PLEASE WAIT A FEW SECONDS WHILE YOU DOCUMENTS
ARE BEING PREPARED FOR ELECTRONIC SIGNATURE.

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