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Email:
First Name:
Last Name:
Nationality:
Date of Birth:
Base Location:
Currency:
Annual Salary:
Rank:
Airline:
Employment Status:
Amount of Cover Required
Permanent Loss of License:

Amount of cover required (Max 300,000)
Temporary Loss of License:

I. Max monthly benefit 75% of salary for up to 24 months.
II. Monthly benefits reduce the lump sum insured.
III. The temporary benefit is limited to 75% of average pre-disability income in the last 6 months prior to the claim.

Psychological Benefit: