AVIATION – ACCIDENT CLAIM FORM
1. DETAILS OF INSURED (a) Named Insured (list all owners/ operators) (b) Aircraft Type (c) Address of Insured (d) Business Telephone (e) Policy Number Registration
A/H Telephone Expiry Date
Fax Number Claim Number Yes No __________________ %
(f) Are you registered for GST? If Yes, to what extent (%) are you entitled to claim an Input Tax Credit on your premium? What is your Australian Business Number (ABN) (if applicable)? 2. PARTICULARS OF ACCIDENT (a) Date of Accident (b) Site/Location of Accident (c) Nature of Flight (eg Private, Charter etc) (d) Stage of Flight or Operation (e) Pilot Name (f) Pilot Address Telephone
ABN:________________________________
Time of Accident
a.m./p.m.
Fax
(g) Passenger Names (h) Injuries (i) All-up Weight at Time of Accident Maximum Permitted All-up Weight
(j)
Please provide details of ACCIDENT in the box below (if more space is required, please attach a separate sheet of paper):
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INSURED’S INITIALS …………….
(k) Please provide details of AIRCRAFT DAMAGE in the box below (if more space is required, please attach a separate sheet of paper):
(l)
Please complete the following (as applicable): Alignment Wet/Dry Wind Strength Cloud Yes No Surface ALA/PVTE/AG Visibility
Strip Length Level/Incline Wind Direction Ambient Temperature
(m) Was there any third party injury? If “Yes”, please provide details in box below:
(n) Was there any third party property damage? If “Yes”, please provide details in box below:
Yes
No
(o) Give names, addresses and telephone numbers of all witnesses of the accident in the box below Name 1. 2. 3. 4. (p) Please provide details regarding the cause of the accident in box below: Address Contact Numbers
(q) Was the aircraft operated in accordance with CAR’s and CAO’s? (r) In your opinion, was the accident caused or contributed to by the actions or negligence of any party or persons? If “Yes”, please provide a full description in box below:
Yes Yes
No No
3. PILOT DETAILS (a) Licence No (b) Total Hours (c) FIXED WING Hours Piston
Licence Type Hours on Type
Last Medical Hours in last 90 days FIXED WING Hours Turbine
/
/
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INSURED’S INITIALS …………….
(d) HELICOPTER Hours Piston (e) Type Endorsement? (f) Last Annual Review (g) AGRICULTURAL HOURS Helicopter (h) Ag Rating 1 (i) Other Endorsements Yes No Ag Rating 2 Yes Date: / No /
HELICOPTER Hours Turbine Date Given By Whom AGRICULTURAL HOURS Fixed Wing Yes No Hours since issue 1. 2. / /
4. AIRCRAFT DETAILS DOCUMENT (a) Maintenance Release: (b) Certificate of A/C Reg: (c) Maintenance Release Issued by: (d) M/R Hours Since Issue: (e) Aircraft Type/Model: (f) Total Time on Airframe: (g) Engine Type/Model: ENGINE ID (h) Left/Front (i) Right (j) Propellors Type/Model: PROPELLOR ID (k) Left/Front (l) Right
NUMBER
ISSUE DATE
EXPIRY DATE
Serial No: Major Inspection Due (If applic): TBO: SINCE NEW (Hrs) SINCE O/H (Hrs) TO RUN TO O/H
SERIAL NUMBER
TBO: SINCE NEW (Hrs) SINCE O/H (Hrs) TO RUN TO O/H
SERIAL NUMBER
5. OTHER INFORMATION Are there any other disclosures you wish to make in connection with this matter? If “Yes”, please provide details in the box below:
Yes
No
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INSURED’S INITIALS …………….
6. NOTES 1. It is important that no removal of, or repairs to, the aircraft be made or authorised (except to ensure the safety of the aircraft) without prior notification to Insurers and/or surveyors acting on behalf of insurers. Following notification and approval of the foregoing IT REMAINS THE RESPONSIBILITY OF THE INSURED TO AUTHORISE REMOVAL AND/OR REPAIRS. 2. If this form is to be signed by an Agent of the Insured, an appropriate Letter of Authority should be attached hereto.
DECLARATION BY INSURED
I/WE HEREBY DECLARE THE FOREGOING PARTICULARS PROVIDED ON THE PAGES OF THIS FORM TO BE TRUE IN EVERY RESPECT AND THAT NO INFORMATION HAS BEEN EXAGGERATED, OMITTED OR WITHHELD, AND THAT THE LOSS/DAMAGE CLAIMED REPRESENTS THE LOSS/DAMAGE I/WE ARE ENTITLED TO CLAIM IN TERMS OF THE POLICY AND THE INSTRUCTIONS CONTAINED THEREIN. I/WE ACKNOWLEDGE THAT THE INSURER MAY GIVE TO, AND OBTAIN FROM, OTHER INSURERS AND/OR INSURANCE REFERENCE SERVICES, PERSONAL INFORMATION AS WELL AS INSURANCE CLAIMS INFORMATION OBTAINED DURING THE COURSE OF THE INSURANCE CONTRACT.
NAME OF INSURED/AGENT AGENT'S ADDRESS SIGNATURE DATE
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OAMPS Aviation
A Division of OAMPS Insurance Brokers Ltd ABN 34 005 543 920
Phone: 1800 025 481 E-mail: aviation@oamps.com.au
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INSURED’S INITIALS …………….
PRIVACY COLLECTION STATEMENT - OAMPS INSURANCE BROKERS
OAMPS Insurance Brokers Ltd, as part of the OAMPS group of companies, is committed to ensuring the confidentiality and security of your personal information. The OAMPS Privacy Policy detailing our handling of personal information is available on request. You may request access to information held by us about you, by contacting your local OAMPS office. The information we collect will be used for the purpose of providing insurance broking services to you. This includes the provision of premium funding information and insurance related information that may help you to understand the financial impact of risks to which you may be exposed. Failure to provide all the personal information requested might expose you to higher risks in respect of the recommendations made to you and may affect the adequacy or appropriateness of advice we give to you. If we do not collect sufficient information we may not be able to assist you. To provide these services, it will be necessary for us to disclose your personal information to insurance companies (for the provision of insurance cover) and other organisations including those which: Provide underwriting services on behalf of insurance companies; Assess claims; Undertake compliance reviews of our insurance brokers and financial advisers or reviews of the accuracy and completeness of our information; Provide finance for premium funding; Provide mailing services, maintenance of our information technology systems, and printing of our standard documents and correspondence. Your health and other sensitive information will only be disclosed to the insurance companies and other service providers such as doctors and assessors who are directly involved in underwriting your policy or the assessment of any claim. Your health information will not be disclosed by OAMPS for any other purpose. We will disclose your personal information to any other adviser where you have authorised that person to act on your behalf. Should you wish to amend or withdraw your authority for that adviser to act on your behalf, please advise us in writing. We will collect information from any parties that act on your behalf or that are authorised by you to provide information to us. We need to collect all the relevant information that insurance law and practice require to be disclosed to an insurer. We may therefore contact existing insurers or third parties to collect (or verify) any such relevant information. We regularly distribute to our clients general information and newsletters regarding OAMPS products and services. From time to time we may wish to supply you with specific information regarding some of our products and services, which we believe may be of interest to you. Please complete a separate advice if you do not wish to receive this additional (directly marketed) information. When you provide us with personal information about other individuals, we rely on you to have made them aware that you will or may provide their information to us, and the purpose and other matters set out in this notice. If it is sensitive information we rely on you to have obtained their consent. (Sensitive information includes among other things, membership of professional associations or trade unions, criminal record and health information.) If you have not done either of these things, you must tell us before you provide that information.
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INSURED’S INITIALS …………….