Aircraft Insurance Application
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General Information
Applicant
Last Name
First Name
Address
Street
City
State
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
United States Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Zip Code
Home Number
Work Number
E-mail Address
Applicant's Business is
Current Insurance Carrier
Current Coverage Expires
(check all that apply)
Applicant is an Individual
Applicant is a Corporation
Applicant is an Partnership * (explain below)
Applicant is Other * (explain below)
Aircraft will be operated under FAR Part 135
Airecraft will be managed by other party (not Applicant)
* Please provide the names of each partner
if a Partnership or explain the entity if
"Other" box checked above.
Aircraft Information
0 Items
FAA "N" No
Year
Make & Model
Crew Seats
Passengers Seats
Insured Value
Liability Limit
Aircraft are based at the following airport(s)
Aircraft hangared or tied outside?
Average number of passengers per flight
Annual hours each aircraft operated with a single pilot crew
Purpose for use of Non-Owned aircraft, if applicable
Non-Owned aircraft types utilized by the Applicant
Non-Owned aircraft annual number of flights
From whom are Non-Owned aircraft rented, borrowed, chartered
List names and addresses of loss payees and lien holders
0 Items
Last Name
First Name
Street
City
State
Zip
Purpose of Use
0 Items
FAA "N" No
P & B
Industrial Aid
Charter / Air Taxi
Other
Est Annual Hrs
Named Pilots
(attach a Pilot Record Form for each pilot, Form No. 001)
0 Items
Last Name
First Name
Pilots are
Employees of the Applicant
Contract Pilots
Other
Other
Pilot(s) complete Annual Factory sim-based
training in insured make & model aircraft.
(please detail fully on pilot record form)
Yes
No
Additional Information
Name of Charter or Management company (if applicable)
Charter
Certificate No
Years in Business
Base of Operations
Aircraft Maintenance provided by:
Aircraft Maintenance provided by:
Does Applicant employ their maintenace personnel?
Yes
No
Will insured aircraft be used on other than paved runways?
Yes
No
Does Applicant own or exclusively lease any other aircraft?
Yes
No
Does Applicant have any Non-Owned Aircraft exposure?
Yes
No
Will anyone other than named pilots operate the insured aircraft?
Yes
No
Will insured aircraft be used outside the continental United States?
Yes
No
Will insured aircraft be used for anything other than transporting passengers?
Yes
No
Has Applicant or Named Pilot(s) ever had any incidents, accidents, or violations?
Yes
No
Has Applicant or Named Pilot(s) ever had any felony convictions or license suspensions?
Yes
No
Has Applicant ever had insurance denied or cancelled?
Yes
No
Explain all YES answers
5-YEAR LOSS HISTORY
attach loss runs if available
Drop files to upload
Click to Add a New Attachment
Signature
I certify that the statements in this form are true and that no material information has been withheld or suppressed.
Name
Date
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