Please provide the following information:

Name of Applicant:
(person or business)
If business, contact name:
Address:
City/State:
Zip:
Home Phone:
Work Phone:
Fax:
E-Mail:
Current Policy Expiration Date:
Current Insurance Company:
Current Insurance Agency:
Make and Model of Aircraft:
No. of seats (including pilot):
Year of Aircraft:
Is Aircraft Hangared? Yes No
At what airport?
Total Time Airframe:
Value of Aircraft: $
Aircraft Registration #: N

Liability Limits Desired:


Physical Damage Coverage:



Pilot Information
No. of pilots who fly aircraft:
If more than three pilots, please contact us at our toll-free number, 800-358-8079.

Pilot #1
First Name:
Last Name:


Certification:

CFI
CFII
MEI
VFR
IFR
Multi-Engine
Seaplane
Rotary Wing
Glider
Other

Date of Birth:
Date of last BFR:
Date of last Medical:


Class of Medical:
Total Logged Hours:
Total Hours in make/model to be insured:


If applicable: (List in hours)
Retractable Gear:
Tail Wheel:
Multi-Engine:
Seaplane:

Losses within last 5 years:
Yes No
DUI within last 5 years:
Yes No
Insurance Cancelled in last 5 years:
Yes No
Pilot #2
First Name:
Last Name:


Certification:
CFI
CFII
MEI
VFR
IFR
Multi-Engine
Seaplane
Rotary Wing
Glider
Other
Date of Birth:
Date of last BFR:
Date of last Medical:


Class of Medical:
Total Logged Hours:
Total Hours in make/model to be insured:


If applicable: (List in hours)
Retractable Gear:
Tail Wheel:
Multi-Engine:
Seaplane:

Losses within last 5 years:
Yes No
DUI within last 5 years:
Yes No
Insurance Cancelled in last 5 years:
Yes No
Pilot #3
First Name:
Last Name:


Certification:
CFI
CFII
MEI
VFR
IFR
Multi-Engine
Seaplane
Rotary Wing
Glider
Other
Date of Birth:
Date of last BFR:
Date of last Medical:


Class of Medical:
Total Logged Hours:
Total Hours in make/model to be insured:


If applicable: (List in hours)
Retractable Gear:
Tail Wheel:
Multi-Engine:
Seaplane:

Losses within last 5 years:
Yes No
DUI within last 5 years:
Yes No
Insurance Cancelled in last 5 years:
Yes No

If yes, provide remarks in space provided:


By submitting this application, I agree that all of the information is true and correct and that no requested information has been omitted. I understand that this submitted application does not constitute a binder or agreement by any insurer to provide coverage.