Pilot Information

Your Name

Address
City
State
Zip
Phone
Email
AOPA #:
EAA #:

Age

Certificate
STDRECPVTCMLATP

Ratings

Instructor

Other

If other, describe

Total logged hours
Logged hrs. past 12 mos.
What type aircraft usually flown
Your hrs. in PIC in type

Do you have a:
CFI-InstCFI-ME

Flight Instruction given last 12 mos.?
YesNo

Within last 36 months, have you:

Been involved in any accidents?
YesNo

Cited for any FAR violation?
YesNo

Had pilot's or driver's license suspended?
YesNo

Been convicted of any felony or DUI charge?
YesNo

If you answered “Yes” to any of the above, please contact your insurance agent.

Wings Program?
YesNo

Wings Program Phase?

Master CFI?
YesNo

Coverages

Liability Coverage – pays for bodily injury and property damage for
which you are legally liable arising out of your use of non-owned aircraft, but excluding physical damage to non-owned aircraft.

Personal Renter

  • Each Occurrence
    $250,000
    $500,000
    $500,000
    $1,000,000
  • Passengers
    $25,000
    $50,000
    $100,000
    $100,000
  • Premium
    $85
    $114
    $180
    $219
  • Premium w/AOPA
    $80
    $108
    $171
    $208

Select an option

Flight Instructors

  • Each Occurrence
    $250,000
    $500,000
    $500,000
    $1,000,000
  • Passengers
    $25,000
    $50,000
    $100,000
    $100,000
  • Premium
    $200
    $350
    $500
    $650
  • Premium w/AOPA
    $190
    $332
    $475
    $617

Select an option

Physical Damage to Your Non-Owned Aircraft – pays for physical damage to non-owned aircraft for which you are legally liable.This coverage is only available in conjunction with Liability Coverage.

  • Physical Damage Limit
    $5,000
    $10,000
    $20,000
    $30,000
    $40,000
    $60,000
    $80,000
    $100,000
    $150,000
    $200,000
  • Premium
    $99
    $175
    $250
    $350
    $450
    $600
    $775
    $975
    $1,425
    $1,900
  • Premium s/AOPA
    $94
    $166
    $237
    $332
    $427
    $570
    $736
    $926
    $1,353
    $1,805

Select an Option

Optional Coverages

Add my employer as an additional insured ** (Premium - $50)
Name of Employer

Add the Civil Air Patrol Endorsement *** (Premium - 50)

Coverage for Acts of Terrorism under the Terrorism Risk Insurance Act of 2002 (TRIA) (MUST BE COMPLETED) - pays for bodily injury and property damage for which you are legally liable from certified acts of terrorism.

Add TRIA Coverage (Premium - $50)
YesNo

* Flight Instructors Liability now includes comprehensive CFI Liability coverage.