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Current Aviation Insurance Information
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Policy Expiration Date
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Premium Amount ($)
Term
1 Year
6 Months
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If Other
Aircraft Information
Aircraft #1
Year
Make/Model
Engine Type
Horsepower
# of seats
Date Purchased
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Purchase Price
Present Value
Aircraft Cat.
Exp
Std
Aircraft Hangared at
Lienholder
Additional Insured / Address
FAA Reg. #
Aircraft #2
Year
Make/Model
Engine Type
Horsepower
# of seats
Date Purchased
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31
Purchase Price
Present Value
Aircraft Cat.
Exp
Std
Aircraft Hangared at
Lienholder
Additional Insured / Address
FAA Reg. #
Aircraft #3
Year
Make/Model
Engine Type
Horsepower
# of seats
Date Purchased
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Purchase Price
Present Value
Aircraft Cat.
Exp
Std
Aircraft Hangared at
Lienholder
Additional Insured / Address
FAA Reg. #
Pilots/Operators
(always list insured as Pilot #1)
Pilot #1
Name
DOB
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Ratings / Certificates
Logged Hours
Tail Wheel
Retract. Gear
In Model
Last 12 months
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions
Occupation
Pilot #2
Name
DOB
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31
Ratings / Certificates
Logged Hours
Tail Wheel
Retract. Gear
In Model
Last 12 months
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions
Occupation
Pilot #3
Name
DOB
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02
03
04
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12
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31
Ratings / Certificates
Logged Hours
Tail Wheel
Retract. Gear
In Model
Last 12 months
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions
Occupation
Liability Limit For ALL Air crafts
Bodily Injury
Property Damage
Per seat Medical
Hull Coverage For ALL Air crafts
Coverage Type
Amount Requested ($)
Miscellaneous Information
Aircraft Use
Business & Pleasure
Business
Pleasure
Commercial
Passenger Charters
No
Yes
Flight Instructor
No
Yes
Aircraft Hangared
No
Yes
Tied Down
No
Yes
Crop Dusting
No
Yes
Aircraft Based
No
Yes
On Floats
No
Yes
Paved Runway
No
Yes
Airport Name
Airport Location
Additional Comments
Additional Comments