Aircraft Insurance Application

Personal Info

Owner Name

Address
City
State
Zip

Occupation

Day Phone
Fax
Email
AOPA #:
EAA #:

Aircraft

Aircraft #1

Make and Model of Aircraft

Year of Manufacture
No. of seats (including pilot)
Aircraft Registration #
Value

Mods / Special Equipt

Add Another Aircraft

Aircraft #2

Make and Model of Aircraft

Year of Manufacture
No. of seats (including pilot)
Aircraft Registration #
Value

Mods / Special Equipt

Add Another Aircraft

Aircraft #3

Make and Model of Aircraft

Year of Manufacture
No. of seats (including pilot)
Aircraft Registration #
Value

Mods / Special Equipt

Add Another Aircraft

Aircraft #4

Make and Model of Aircraft

Year of Manufacture
No. of seats (including pilot)
Aircraft Registration #
Value

Mods / Special Equipt

Add Another Aircraft

Aircraft #5

Make and Model of Aircraft

Year of Manufacture
No. of seats (including pilot)
Aircraft Registration #
Value

Mods / Special Equipt

Aircraft Based

Is aircraft tied down? YesNo

Is aircraft hangared? 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

PleasureBusinessInstruction & RentalPower/PipelineIndustrial AidAerial PhotoSightseeingCharter

Other (explain)

Aircraft Lienholder

Lienholder Name

Limits of Liability

Liability Limits Desired

Special Requirements

Medical Payments

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