Agricultural Aircraft

AGRICULTURAL INSURANCE APPLICATION

Owner Name

Address
City
Zip

Occupation

Day Phone
Fax

Email

AOPA #:
EAA #:
Years in business

Has Insured had any hull, liability or chemical claims in the past five (5) years? YesNo If yes on insured or business, describe below. If pilot, please complete in pilot section

Aircraft

Year
Make/Model
Engine HP
Seats
Value
GNIM
ARH

Add Another Aircraft

Year
Make/Model
Engine HP
Seats
Value
GNIM
ARH

Add Another Aircraft

Year
Make/Model
Engine HP
Seats
Value
GNIM
ARH

Add Another Aircraft

Year
Make/Model
Engine HP
Seats
Value
GNIM
ARH

Add Another Aircraft

Year
Make/Model
Engine HP
Seats
Value
GNIM
ARH

Aircraft Lienholder

Name of Lienholder Check if mortgagee requires breach of warranty coverage

Aircraft Based

Is the aircraft hangared? YesNo
Is aircraft tied down? YesNo

At what airport?
Airport Identifier

Private Strip YesNo

If Private Strip - Length:
If Private Strip - Surface

Current Insurance Company

Insurance Company
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
Limits of Liability: Chemical

Chemical Coverages Required

Excluding chemicalRestricted chemicalComprehensive chemical

Chemical Coverage To Include

Crops treatedRestricted chemicalFarmer/owner/grower PicloramResidentialOther If "other" checked, explain:

Pilot Information

Pilot #1

Pilot 1 - Name

Pilot 1 - BFR Date
Pilot 1 - Med Date
Pilot 1 - Date of Birth

Pilot 1 - Ratings (Check all qualified ratings) StudentPrivateCommercialInstrumentMulti EngineAirline TransportRotorwing

Total Hours
Last 90 days (Hours)
Last 12 Months (Hours)
Hours in Make/Model
Retract
Multi Engine
Tail Wheel
Turbine
Rotorwing

Annual Proficiency Training YesNo If yes, describe Date of last APT Aircraft claims, accidents, or license Suspensions in the last 5 years? YesNo If yes, describe below

Add Another Pilot

Pilot #2

Pilot 2 - Name

Pilot 2 - BFR Date
Pilot 2 - Med Date
Pilot 2 - Date of Birth

Pilot 2 - Ratings (Check all qualified ratings) StudentPrivateCommercialInstrumentMulti EngineAirline TransportRotorwing

Total Hours
Last 90 days (Hours)
Last 12 Months (Hours)
Hours in Make/Model
Retract
Multi Engine
Tail Wheel
Turbine
Rotorwing

Annual Proficiency Training YesNo If yes, describe Date of last APT Aircraft claims, accidents, or license Suspensions in the last 5 years? YesNo If yes, describe below

Add Another Pilot

Pilot #3

Pilot 3 - Name

Pilot 3 - BFR Date
Pilot 3 - Med Date
Pilot 3 - Date of Birth

Pilot 3 - Ratings (Check all qualified ratings) StudentPrivateCommercialInstrumentMulti EngineAirline TransportRotorwing

Total Hours
Last 90 days (Hours)
Last 12 Months (Hours)
Hours in Make/Model
Retract
Multi Engine
Tail Wheel
Turbine
Rotorwing

Annual Proficiency Training YesNo If yes, describe Date of last APT Aircraft claims, accidents, or license Suspensions in the last 5 years? YesNo If yes, describe below

Add Another Pilot

Pilot #4

Pilot 4 - Name

Pilot 4 - BFR Date
Pilot 4 - Med Date
Pilot 4 - Date of Birth

Pilot 4 - Ratings (Check all qualified ratings) StudentPrivateCommercialInstrumentMulti EngineAirline TransportRotorwing

Total Hours
Last 90 days (Hours)
Last 12 Months (Hours)
Hours in Make/Model
Retract
Multi Engine
Tail Wheel
Turbine
Rotorwing

Annual Proficiency Training YesNo If yes, describe Date of last APT Aircraft claims, accidents, or license Suspensions in the last 5 years? YesNo If yes, describe below