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Home» Forms » Loss of Licence Renewal – 2019

Loss of Licence Renewal – 2019

Your Longreach Aviaton Loss of Licence policy renews on the 1st September 2019.

Please use the form below to change your enrolment in the scheme.

If you have any questions then just drop us an email or give us a call to discuss.

2019 Loss of Licence Renewal

Date*
Date Format: DD slash MM slash YYYY
Name*
First Last
Email*
Contact Number*
Loss of Income*
- No change to current selection
- I wish to cancel my Loss of Licence cover
- I wish to change my selection as indicated below...
Loss of Licence Income Benefit
Please select your desired income benefit level*
Please Note:
Standard benefit period is 24 months, plus USD150,000 termination payment for permanent disablement is included.
- Level 1 - USD10,000/mth with 90 day waiting period
- Level 2 - USD10,000/mth with 60 day waiting period
Optional Lump Sum Benefit
Please Note: This section is optional
Here you may select an additional amount of lump sum benefit which will be added to the standard amount of USD150,000 included with the standard LOI policy.
The amount of additional lump sum is dependent on your age.
Please refer to the information included in the email sent to you.
Please select an additional lump sum benefit*
- No additional lump sum
- USD100,000 (total lump sum USD250,000)
- USD200,000 (total lump sum USD350,000)
- USD300,000 (total lump sum USD450,000)
- USD400,000 (total lump sum USD550,000)
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