Authorised and Regulated by the Financial Conduct Authority s1

Hang Gliding

Contact name:

IFA company name:

Telephone number:

Email: GENERAL INFORMATION

Full name of life proposed Sum Assured Preferred Monthly Premium

Title (Mr, Mrs, Miss, other) Period of Policy

Date of Birth Level/Decreasing Term Assurance

Height Weight Have you smoked in the last 12 months?

INFORMATION ABOUT YOUR HANG GLIDING

Rating Date obtained None ٱ Please indicate the type of hang-gliding proficiency rating that you have. ______Elementary pilot ٱ ______Club Pilot ٱ ______Pilot / Cross country ٱ ______Advanced pilot ٱ ______:Other ٱ ______

Are you an instructor? Yes / No

Are you a member of a sanctioned hang-gliding club or national Yes / No organization? If yes, please provide details.

How long have you been hang-gliding? Years Months

Please provide the following hang-gliding details for the last 12 Number of flights: months. Number of hours:

Please provide the following hang-gliding details, estimated for the Number of flights: next 12 months: Estimated hours:

Please describe the nature of the terrain over which you usually fly, e.g. coastal, lakes, mountainous, open country etc.

In the past 3 years, have you:- Yes / No  participated in any hang-gliding competitions?  participated in endurance events, cross country, aerobics or air slalom etc? If Yes, please provide details.

Pulse Insurance Limited Authorised and Regulated by the Financial Conduct Authority 6 Oxford Court, St James Road, Brackley, Northants, NN13 7XY Tel: 01280 841430 Fax: 01280 702977 E-mail: [email protected] .uk Website: www.pulse-insurance.co.uk For the next 12 months, do you intend to Yes / No  participate in any hang-gliding competitions?  participate in endurance events, cross country, aerobics or air slalom etc? If Yes, please provide details.

In the past 3 years, have you ever used a powered, experimental, Yes / No prototype or home built glider? If yes, please provide details.

Do you intend to use a powered, experimental, prototype or home Yes / No built glider in the next 3 years? If yes, please provide details.

Do you intend to take part in hang-gliding record attempts in the Yes / No next 3 years? If Yes, please provide details.

Have you ever had an accident or sustained an injury as a result of Yes / No your hang-gliding activities? If Yes, please provide details.

Signed (client or IFA): Date:

Pulse Insurance Limited Authorised and Regulated by the Financial Conduct Authority 6 Oxford Court, St James Road, Brackley, Northants, NN13 7XY Tel: 01280 841430 Fax: 01280 702977 E-mail: [email protected] .uk Website: www.pulse-insurance.co.uk