Helicopters Header Image

Pilot Loss of License insurance application

Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

To receive a quick, non-binding price estimate for Pilot Loss of License insurance, please complete this form. It should take approximately 5 minutes to complete. Please contact a dedicated Lockton Affinity team member for assistance at 844-455-5963 or hai@locktonaffinity.com and reference this indication form.

After completing this form, you will have the option to submit this application and apply for coverage. If your application is approved, you will receive your policy documents and invoice within 5 to 10 business days.

1. Proposed Insured*
For questions regarding your HAI membership please email member@rotor.org.



Residential Address*



Gender*
2. Date of Birth*

Employment Information

5. Flight Category*
Aircraft Category*

Elimination Period

Which elimination period (the amount of time between an injury and the receipt of benefit payments) would you prefer?*

License Information

Current license held*
Date of last FAA medical exam*
Date of last Biennial Flight Review (BFR)*
8. Have you ever been grounded or had your license invalidated for medical reasons?*
9. Have any limitations ever been endorsed on your license?*



Please upload a copy of your aviation license and FFA medical card.

Aviation license
No File Chosen
File uploads may not work on some mobile devices.
Aviation license file type
FFA medical card
No File Chosen
File uploads may not work on some mobile devices.
FFA medical card file type



Health and Insurance History

10. Have you ever had any Life, Health or Accident insurance canceled or declined?*
11. Are you currently insured against accident or illness by you or your employer?*
12. Are you aware of any deterioration in your general health, hearing, eyesight or blood pressure? *
13. Do you presently take any medications, including over the counter or prescription medicine(s)?*
14. Have you even been treated for or had any indication of:*
14. Have you even been treated for or had any indication of:
  Yes No
Disorder of the eyes, ears, nose or throat?
Dizziness, fainting, convulsions or headache; speech defect paralysis or stroke; mental or nervous disorder?
Shortness of breath, persistent hoarseness, cough or bronchitis; pleurisy, asthma, emphysema, tuberculosis or lung disorder?
Chest pain, high blood pressure, stroke, rheumatic fever, heart murmur, heart attack, or other disorder of the heart or circulatory systems?
Cirrhosis, hepatitis, ulcer, colitis, diverticulitis, ileitis, jaundice, or an other disease of the liver, gall bladder, pancreas, stomach or intestines?
Sugar, albumin, blood or pus in urine; nephritis, stone or other disorder of the kidney or bladder?
Disorder of the reproductive organs, prostate or testicular disease; or disease of the uterus, ovaries or breasts; complications of pregnancy?
Diabetes, thyroid, or other endocrine disorders?
Neuritis, sciatica, arthritis, gout, or disorder of the muscles or bones including the spine, back or joints
Disorder of the skin, lymph glands, cyst, tumor or cancer?
Allergies, anemia, leukemia or other blood disorder?
15. After or during a medical examination:*
15. After or during a medical examination:
  Yes No
Have you ever been required to take additional test?
Have you ever been referred to a specialist for an examination?
Have you ever had the issue or renewal of your medical certificate deferred?
Have you ever had to return for examination at less than the normal interval time?
Have you ever been ordered to take drugs or follow any specific diet?

Annual Premium Quote Indication

We’re sorry, your selected age range is not eligible for our online price indication. However, you may still be eligible to purchase a policy. Please complete and submit this online form for further underwriting review and approval.  

$

Before applicable taxes and/or fees

$
$

Before applicable taxes and/or fees

Please note this is an indication of premium. This is not an offer for coverage. Final quote is subject to underwriters review and approval. No risk shall be bound until the carrier issues a certificate or policy evidencing coverage. If your application is approved, you will receive policy documents and an invoice from HAI's program underwriter, Exceptional Risk Advisors, LLC. 

DECLARATION

I declare that the above statements are true and complete, and that, apart from the matters declared above, I am in good health and ordinarily enjoy good health. I agree that this proposal shall form the basis of the contract should the insurance be effected and any misstatements above may be grounds for rescission. I understand that pre-existing condition are not covered until a period of insurance of 12 months, treatment free, has elapsed.

FRAUD WARNING

Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing any false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

I, the Proposed Insured, declare that all responses made to each and every question in the Application are truce and complete. I understand that:

A. Any false statements or material misrepresentations shall result in the loss of coverage under any policy and/or certificate which may be in force and/or any coverage which are being offered; and

B. No representation made to or information possessed by any agent shall be binding on the Underwriters and/or the Insurer, unless disclosed in the Application.

Use your mouse or finger to draw your signature above
Date*



AUTHORIZATION

I hereby authorize any physician, medical practitioner, hospital, clinic, veterans administration facility, medical information service including Medical Information Bureau, Inc., urgent care facility, other medically related facility or entity, insurance or reinsurance, pharmacy benefit manager, or Consumer Reporting Agency, having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition including drug or alcohol abuse, and/or treatment of me or my dependents and other non-medical information of me, to release to Underwriters at Exceptional Risk Advisors, LLC, or its designee any and all such information. This authorization includes release of information concerning psychiatric/psychological conditions, prescription history, pharmaceutical records, sexually transmitted diseases (STD’s), human immunodeficiency virus (HIV) and preparation of an investigative consumer report.

I understand that the information obtained by use of the authorization will be used by Underwriters at Exceptional Risk Advisors, LLC, to determine eligibility for insurance or to determine eligibility for benefits under the Policy. Any information obtained will not be released by the Insurer except to reinsuring companies, insurance support organizations or other person or organization performing business or legal services in connection with my application, or as may be otherwise lawfully required. I understand that any information that is disclosed pursuant to this authorization is no longer covered by federal rules governing privacy and confidentiality of health information, but it will not be disclosed by the recipient except as authorized by me or required by law.

I know that I may request to receive a copy of this authorization. I know that I may request to be interviewed if any investigative consumer report is prepared in connection with this application. I agree that a photographic copy of this authorization shall be as valid as the original. This authorization shall be valid for thirty-six (36) months from the date signed. I understand that I have the right to revoke this authorization in writing, at any time, by providing written notification to Exceptional Risk Advisors, LLC.

Date*
Use your mouse or finger to draw your signature above
Powered by Formstack Create your own form ›
Cancel
Confirm