For Help Call  1-877-608-PLANET 
Fields marked (*) are mandatory.
Genral Information
Registered Owner Name*
Address*
City*
State*
Zip*
Day Phone*
Night Phone
Best Time To Call
Email Address*
Current Aviation Insurance Information
Company Name (not agency)
Policy Expiration Date
Premium Amount ($)
Term
If Other
Aircraft Information
Aircraft #1
Year
Make/Model
Engine Type
Horsepower
# of seats
Date Purchased
Purchase Price
Present Value
Aircraft Cat.
Exp
Std
Aircraft Hangared at
Lienholder
Additional Insured / Address
FAA Reg. #
Aircraft #2
Year
Make/Model
Engine Type
Horsepower
# of seats
Date Purchased
Purchase Price
Present Value
Aircraft Cat.
Exp
Std
Aircraft Hangared at
Lienholder
Additional Insured / Address
FAA Reg. #
Aircraft #3
Year
Make/Model
Engine Type
Horsepower
# of seats
Date Purchased
Purchase Price
Present Value
Aircraft Cat.
Exp
Std
Aircraft Hangared at
Lienholder
Additional Insured / Address
FAA Reg. #
Pilots/Operators (always list insured as Pilot #1)
Pilot #1
Name
DOB
Ratings / Certificates
Logged Hours
Tail Wheel
Retract. Gear
In Model
Last 12 months
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions
Occupation
Pilot #2
Name
DOB
Ratings / Certificates
Logged Hours
Tail Wheel
Retract. Gear
In Model
Last 12 months
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions
Occupation
Pilot #3
Name
DOB
Ratings / Certificates
Logged Hours
Tail Wheel
Retract. Gear
In Model
Last 12 months
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions
Occupation
Liability Limit For ALL Air crafts
Bodily Injury
Property Damage
Per seat Medical
Hull Coverage For ALL Air crafts
Coverage Type
Amount Requested ($)
Miscellaneous Information
Aircraft Use
Business & Pleasure
Business
Pleasure
Commercial
Passenger Charters
Flight Instructor
Aircraft Hangared
Tied Down
Crop Dusting
Aircraft Based
On Floats
Paved Runway
Airport Name
Airport Location
Additional Comments
Additional Comments