A.S.P.I.R.E.

Airline Self-employed Personnel Income Replacement Enterprise

Full Name

Email Address

Address

Date of Birth--

Height

Weight

Nature of Business or Occupation in which you are engaged (if more than one please state all)

For which airline do you fly

When do you require cover to start?--

How much benefit do you require if temporarily unable to work? (Max. 70% of gross annual income)

Do you wish to be covered for Winter Sports?*

If yes are competitions to be included?

Do you wish to be covered for Scuba Diving?*

Do you wish to be covered for Rock Climbing or Mountaineering involving ropes or guides?*

Do you wish to be covered for Pot-holing?*

Do you wish to be covered for Hang-gliding or Parachuting?*

Do you wish to be covered for hunting on horseback?*

Do you wish to be covered for driving or riding in any kind of race or competition?*

Do you wish to be covered for riding motorcycles?*

Any other sport, pastime or activity which is likely to involve extra risk of accident*

If Yes to any of the above please provide further details

Do you suffer from defective hearing or vision?

If YES to what extent

Have you ever suffered from hernia, lower back strain, disc lesion or other physical defect of a chronic or recurring nature?

If Yes please provide details

Have you undergone or have you any reason to believe you may need to undergo a surgical operation?

If YES please provide details

Please give details of any accidents or illnesses that have prevented you from attending to your business or occupation for a period of more than 14 days in the last three years

Apart from any matter already disclosed are you now in and do you generally enjoy good health?

If NO please provide details

Are you now insured against accident or illness?

If YES with whom and for what sums insured

Have you ever been declined or accepted on special terms for life, accident, or illness insurance or have Lloyd's underwriters or any company ever cancelled or declined to renew your policy?

If Yes please provide details

*Hobbies /Sports/Pastimes with an increased risk of injury or illness are NOT covered unless specifically agreed by the underwriters.