Aircraft Insurance Application

Please complete the fields below and hit submit to obtain a quote or process a renewal

Applicant's Name *
Application is:
Street Address *
City * State * Zip *
Email *
Phone Number *
If owned, controlled, or a subsidiary of:
Is Applicant incorporated solely for ownership of the aircraft below?
Liability Coverages Limits
Single Limit Bodily Injury & Property Damage, including passengers Each Occurrence $
Single Limit Bodily Injury & Property Damage Liability including limited Passenger Bodily Injury Liability Each Passenger $
Each Occurrence $
Medical Payments
Crew is: 		Each Passenger $
Each Occurrence $
Non-Owned Aircraft Liability Each Occurrence $
Guest Voluntary Settlement
Crew is: 		Each Passenger $
Terrorism Liability (TRIA) Accept
Decline
Physical Damage Coverage Amount of Insurance Deductibles
All Risk: Ground & Flight
All Risk: Not in Flight
All Risk: Not in Motion 		1) $
2) $
3) $ 		In Motion $

Not In Motion $
Terrorism Hull (TRIA) Accept Decline
Aircraft: If Airworthiness Certificate is other than Standard or Normal, please indicate category:
Describe any STC's and Modifications:
1. 2. 3.
Make & Model
Yr
Number(N)
Seating Capacity Crew
Pass
Land(L)
Sea(S)
Amphib(A)
Rotorwing(R)
Purchased New or Used
Date
Price Paid By Applicant (inc. Extras)
Present Estimated Value (inc. Extras)
Engine Hrs. since new or since last overhaul
Engine Make and H/P
Aircraft usually based at:
Does Applicant hangar, service, repair or crew other aircraft?
Describe
Are any unapproved airports or unpaved runways used?
Describe
Is any aircraft registered under other names than Applicant's name above?
Describe
Describe all navigation outside the USA & Canada
List all partners and owned, controlled, affiliated and subsidiary firms:

Purpose of Use
Check All Applicable Uses
Pleasure or Business (not flown by professional pilots employed for this purpose)
Corporate-Executive (flown only by professional pilots employed for this purpose)
Instruction Rental (Commercial) Flying Club Photography
Passenger Carrying for Hire (Charter/Air Taxi) Air Ambulance (Charter/Air Taxi)
Freight Carrying (Charter/Air Taxi) Pipeline / Powerline Patrol
Banner Towing Crop Dusting
List all others:
Pilot Qualifications
AOPA Member Yes No
AOPA Member Number:
Name
Age
Student Yes Yes Yes
PVT. Yes Yes Yes
CML Yes Yes Yes
AMEL Yes Yes Yes
INSTRUM Yes Yes Yes
ATP Yes Yes Yes
CFI Yes Yes Yes
Medical Expiration Date
CLASS
Date of Last B.F.R
Total Time
Total R/G
Total M/E
Total Tail-wheel
Total Turbine FW/RW
Total in Aircraft Model to Be Insured
Total Past 12 months in insd. acft. /in all acft.
Do any pilots named above have any:
(a) physical impairments?
(b) waivers, limitations, conditions attached to medical certificates?
Has an FAA or Military Pilot Certificate held by any pilot named above ever been suspended or revoked?
If so, explain
Has any pilot named above ever been cited for any violation of Federal Air Regulations?
If so, explain
Has any Pilot named above ever been involved in any aircraft accident?
If so, explain
Has any applicant, or officer of partner thereof, or pilot turned above ever been indicated for or been arrested for a felony, drunk or reckless driving?
If so, explain
Has any applicant, or officer of partner thereof, or pilot been convicted in or indicted in a legal action involving drugs?
Applicant is:
Sole Owner of the aircraft
Owner subject to mortgage or conditional sales contract
Other - explain
If aircraft is mortgaged, name and address of mortgagee:
Amount of mortgage (excluding interest and finance charges) $
Will Breach of Warranty Coverage be required by mortgagee
Are any other Aircraft or helicopters owned by, rented or used by or on behalf of Applicant?
Model Aircraft/helicopter
Uses
No. of hours per year
Name of last Aircraft insurance carrier (if none so state)
Expiration date
Describe all incidents, accidents, claims (hull and liability) with dates and amounts paid (even if none), which occurred in the last five years
Has any Insurance Company or Underwriter at any time declined an aircraft application submitted by or cancelled or refused to renew an aircraft policy held by the applicant or any of the pilots herein? -Yes - No If so, explain.