AVIATION APPLICATION

To request a quote please fill out the entire application and we will be back in touch to you with in 48 hours.

Applicant Information:

Name

Address Line 1

City

State

 

ZIP

Occupation

Applicant is

Insurance requested to be effective from to

from :
to:

Liability Coverage:

Single Limit bodily injury and property damage liability:

Passengers:

Limits of Liability Desired for Each Passenger

Limits of Liability Desired for Each Occurrence

Other liability:

Limits of Liability Desired for Each Passenger

Limits of Liability Desired for Each Occurrence

Medical Expense:

Crew:

Limits of Liability Desired for Each Passenger

Physical Damage Coverage:

Aircraft 1:

Amount of insurance Desired

Deductibles:

In motion

Not In motion

Aircraft 2:

Amount of insurance Desired

Deductibles:

In motion

Not In motion

Aircraft Information:

If Airworthiness Certificate is other than Standard, please explain

If engine is being operated beyond TBO, please explain

Aircraft 1:

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Year, make and Model

FAA Registration Number

Seating Capacity for Crew

Seating Capacity for Other

 

Purchased

Purchase Date

Current Market Value

Number of hours aircraft flown in in last 12 months

Est. No. of hours next 12 months

Aircraft 2:

Year, make and Model

FAA Registration Number

Seating Capacity for Crew

Seating Capacity for Other

 

Purchased

Purchase Date

Current Market Value

Number of hours aircraft flown in in last 12 months

Est. No. of hours next 12 months

 

Aircraft usually based at

 

Are any flights contemplated outside continental U.S.?

If yes, where

Purpose of Use

Please check all that apply

Pleasure

Business (not flown by professional pilots employed for this purpose)

Instruction

Corporate Executive (flown by professional pilots employed for this purpose)

Flying club

Low Altitude Photography

Patrol Flights

Banner Towing

Crop Dusting

Air Ambulance

Air Hearse

Use for which a charge is made

Explain:

Other Uses not indicated

Explain:

If used under FAR 135, who owns the FAR 135 Operating Certificate that you operate under?

Who maintains operational control of all aircraft being operated under FAR 135

Pilots:

Complete this section for every pilot who will operate an aircraft during the policy term unless a pilot questionnaire is completed by the pilot.

Pilot 1:

Name

Date of birth

Certification and Ratings:

Stud.

Pvt.

Coml

ASEL

AMEL

Instrumt.

ATP

Other

Medical Certificate:

Date of Last Physical

Class

Hours logged as pilot in command for ALL aircraft:

Total

Last 90 Days

Last 12 Months

Retract Gear

Multi-engine

Hours logged as pilot in command of Aircraft Model to be insured:

Total

Last 90 Days

Last 12 months

FAA Certificate Number

Date of last biennial flight review

Details of other proficiency training

Name and address of pilots employer if other than applicant

Pilot 2:

Name

Date of birth

Certification and Ratings:

Stud.

Pvt.

Coml

ASEL

AMEL

Instrumt.

ATP

Other

Medical Certificate:

Date of Last Physical

Class

Hours logged as pilot in command for ALL aircraft:

Total

Last 90 Days

Last 12 Months

Retract Gear

Multi-engine

Hours logged as pilot in command of Aircraft Model to be insured:

Total

Last 90 Days

Last 12 months

FAA Certificate Number

Date of last biennial flight review

Details of other proficiency training

Name and address of pilots employer if other than applicant

Pilot 3:



Name

Date of birth

Certification and Ratings:

Stud.

Pvt.

Coml

ASEL

AMEL

Instrumt.

ATP

Other

Medical Certificate:

Date of Last Physical

Class

Hours logged as pilot in command for ALL aircraft:

Total

Last 90 Days

Last 12 Months

Retract Gear

Multi-engine

Hours logged as pilot in command of Aircraft Model to be insured:

Total

Last 90 Days

Last 12 months

FAA Certificate Number

Date of last biennial flight review

Details of other proficiency training

Name and address of pilots employer if other than applicant

Pilot 4:

Name

Date of birth

Certification and Ratings:

Stud.

Pvt.

Coml

ASEL

AMEL

Instrumt.

ATP

Other

Medical Certificate:

Date of Last Physical

Class

Hours logged as pilot in command for ALL aircraft:

Total

Last 90 Days

Last 12 Months

Retract Gear

Multi-engine

Hours logged as pilot in command of Aircraft Model to be insured:

Total

Last 90 Days

Last 12 months

FAA Certificate Number

Date of last biennial flight review

Details of other proficiency training

Name and address of pilots employer if other than applicant

Explain Circumstances:

Any pilots named above have any physical impairments, waivers, limitations, conditions on their medical certificates or on their airman certificates.

An FAA, Military, or other pilot certificate held by any pilot named above has ever been suspended or revoked.

Any pilot above that has ever been cited for violation of any aviation regulations in any country.

Any pilot named above has ever been involved in any aircraft accident

Any pilot named above has ever been convicted of or plead guilty to a felony or driving while intoxicated

 

Applicant is:

Other, Please explain

If aircraft is encumbered, name and address of lienholder or lessor

Amount of encumbrance

Will breach of warranty coverage be required by lienholder?

Member of NBAA?

If yes membership type:

Name of last aviation insurance carrier (if none state so)

Has any insurance company or underwriter at any time declined an application submitted by or cancelled or refused to renew a policy held by the applicant or any of the pilots names herein regard to any type of insurance?

If so explain: