AVIATION INSURANCE APPLICATION "*" indicates required fields Step 1 of 5 20% Coverage Status & Contact InformationName of Insurance Company:* Coverage effective dateFrom* MM slash DD slash YYYY To* MM slash DD slash YYYY Name of Applicant:* Applicant is:* An individual A business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact Info:Phone*E-mail:* Occupation:* Is applicant sole owner of the aircraft:* Yes No (If No, explain):*Name of lienholder(s):* Lien amount: $*Address of lienholder(s):* Is Breach of warranty coverage required?* Yes No Name of current insurance company:* Expiration date:* MM slash DD slash YYYY Has the applicant ever had any aviation claims, incidents, accidents, FAR violations DUI's, felony convictions, or been under indictment?* Yes No If "Yes", please explain each occurrence on separate sheet.* AIRCRAFT INFORMATIONUse of Aircraft: (If other than for "Pleasure and Business" please also contact your agent.) "Pleasure and Business" meaning used in the applicant's business, including personal and pleasure uses, but excluding any operation for hire or reward. If any other uses, explain:*Year, Make and Model* Policy Value* Current Value* FAA#* Seats - Crew* Seats - Passengers* Hangared?* Yes No Land Plane?* Yes No Time SMOH* Annual Utilization* Base FAA ID* Will the aircraft be operated at other than paved public airports?* Yes No (If "Yes", where and how often?):*Will the aircraft be operated outside the 48 contiguous states?* Yes No (If "Yes", explain):*Will other than applicant have use of the aircraft?* Yes No (If "Yes", explain):*Does the aircraft have other than a standard airworthiness certificate?* Yes No (If "Yes", explain):*Has the aircraft been modified or converted in any way from the manufacturer's original configuration or design in such a manner to have required a Supplemental Type Certificate (STC)?* Yes No (If "Yes", explain): PILOT INFORMATIONPilot Name* Birth Date* MM slash DD slash YYYY Certs and Ratings* Last BFR Date* MM slash DD slash YYYY Last IPC Date* MM slash DD slash YYYY AOPA#* EAA#* HoursTotal* Retract* Tail* Multi* Rotor* Sea* Turbine* Last 12* Insured AircraftTotal* Last 12* Please Select* FAA Medical BasicMed Sport Medical Date and Class* Last Online Medical Course Date* Has this pilot had any FAA Medicial waivers?* Yes No (If "Yes", please explain)*Has this pilot ever had any aviation claims, incidents, accidents, FAR violations DUI's, felony convictions, or been under indictment?* Yes No (If "Yes", please explain)*Date and Location of last recurrent training:* Is there another pilot? Yes No Pilot Name* Birth Date* MM slash DD slash YYYY Certs and Ratings* Last BFR Date* MM slash DD slash YYYY Last IPC Date* MM slash DD slash YYYY AOPA#* EAA#* HoursTotal* Retract* Tail* Multi* Rotor* Sea* Turbine* Last 12* Please Select* FAA Medical BasicMed Sport Medical Date and Class* Last Online Medical Course Date* Has this pilot had any FAA Medicial waivers?* Yes No (If "Yes", please explain)*Has this pilot ever had any aviation claims, incidents, accidents, FAR violations DUI's, felony convictions, or been under indictment?* Yes No (If "Yes", please explain)*Date and Location of last recurrent training:* COVERAGELiability: Single Limit Bodily Injury & Property Damage Including Passengers, $1,000,000 per occurence, $100,000 sublimit per passengerMedical: Medical payments, $5,000 per passengerHas the applicant had aircraft hull or liability insurance cancelled by an insurance company or underwriter? (Does not apply to MO)* Yes No (If Yes, explain):* Additional Insureds:* Consent* All particulars herein are true and complete to the best of my knowledge and no information has been withheld or suppressed and I agree that this Application and the terms and conditions of the policy in use by the insurer shall be the basis of any contract between me/us and the Insurer. Thereby authorize this Company to investigate all or any qualifications or statements contained herein.*Signature*FRAUD WARNINGVirginia - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
