AGRICULTURAL INSURANCE QUOTE

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Owner Name
Address
City
Zip
Occupation
Day Phone
Fax
Email
Years in business
Has Insured had any hull, liability or chemical claims in the past five (5) years?  Yes No
If yes on insured or business, describe. If pilot, please complete in pilot section
Aircraft
Year Make/Model Engine HP Seats Value GNIM ARH
Aircraft Lienholder
Lien & Total Del
Check if mortgagee requires breach of warranty coverage
Aircraft Based
Is the aircraft hangared?  Yes  No
Is aircraft tied down?  Yes  No
At what airport?
Airport Identifier
Private Strip  Yes  No
If Private Strip - Length::
If Private Strip - Surface:
Current Insurance Company
Underwriter
Expiration Date
Aircraft Usage - Check all that apply
Application of chemical, seeds & fertilizers
Pleasure & Business (excluding any operation for which a charge is made
Sales Demonstration
Fire and/or forest patrol
External load
Mosquito
Other (explain)
Limits of Liability
Non Chemical
Chemical
Coverages Required
 Excluding chemical Restricted chemical Comprehensive chemical
Chemical Coverage To Include
 Crops treated Restricted chemical Farmer/owner/grower
 PICLORAM Residential Other
If "other" checked, explain:
Pilot Information
Pilot 1 - Name
Pilot 1 - BFR Date
Pilot 1 - Med Date
Pilot 1 - Date of Birth
Pilot 1 - Ratings (Check all qualified ratings)  STD PVT COML IFR ME ATP
Total Hrs Retract Multi Eng Tail Wheel Turbine Hrs. Model Last 90 days
Annual Proficiency Training Yes  No 
If yes, describe
Date of last APT
Claims, accidents, Suspensions? Yes  No 
If yes on above, describe

If finished, click here to go to submit button. If additional pilots need to be added, please continue below ...

Pilot 2 - Name
Pilot 2 - BFR Date
Pilot 2 - Med Date
Pilot 2 - Date of Birth
Pilot 2 - Ratings (Check all qualified ratings)  STD PVT COML IFR ME ATP
Total Hrs Retract Multi Eng Tail Wheel Turbine Hrs. Model Last 90 days
Annual Proficiency Training Yes  No 
If yes, describe
Date of last APT
Claims, accidents, Suspensions? Yes  No 
If yes on above, describe

If finished, click here to go to submit button. If additional pilots need to be added, please continue below ...

Pilot 3 - Name
Pilot 3 - BFR Date
Pilot 3 - Med Date
Pilot 3 - Date of Birth
Pilot 3 - Ratings (Check all qualified ratings)  STD PVT COML IFR ME ATP
Total Hrs Retract Multi Eng Tail Wheel Turbine Hrs. Model Last 90 days
Annual Proficiency Training Yes  No 
If yes, describe
Date of last APT
Claims, accidents, Suspensions? Yes  No 
If yes on above, describe

If finished, click here to go to submit button. If additional pilots need to be added, please continue below ...

Pilot 4 - Name
Pilot 4 - BFR Date
Pilot 4 - Med Date
Pilot 4 - Date of Birth
Pilot 4 - Ratings (Check all qualified ratings)  STD PVT COML IFR ME ATP
Total Hrs Retract Multi Eng Tail Wheel Turbine Hrs. Model Last 90 days
Annual Proficiency Training Yes  No 
If yes, describe
Date of last APT
Claims, accidents, Suspensions? Yes  No 
If yes on above, describe

Submit