Contact Information

Applicant Name: Contact Person: Phone: Alt Phone: Email: Business of Applicant: Address: City: State: Zip Code:


Aircraft Information

Year: Make and Model: N #
Number of Crew Seats Number of Passenger(s) Seats Is the aircraft Hangared?
Airport Aircraft is based at Identifier City: State:

 


Applicant is:

New Purchase

Currently Insured

Insurance Co.: Expiration Date of Current Policy:

Date Insurance is Requested to Start:

PHYSICAL DAMAGE COVERAGE: All Risk Ground & Flight

Insured Value Alt Insured Value

LIABILITY COVERAGE & LIMITS

For Bodily Injury & Property Damage Including Passenger Liability
Alt Limit

PURPOSE OF USE: Check all applicable uses

Pleasure and Business, Non-Commercial
Industrial Aid, Corporate/Executive (pro pilots)
Part 135 On-Demand Charter

APPLICANT IS:

AIRCRAFT OPERATION

Number of hours aircraft flown Past 12 months: Est. flight hours in Next 12 months:
Aircraft will be operated in:

Mexico
Canada
Europe

Other:
Average Passenger Load:
Are the Pilot(s) Employees or Contract Pilot(s)?

Pilot(s) are employees
Pilot(s) are contract pilots


LOSS HISTORY AND PREVIOUS AVIATION INSURANCE

(Please explain if the answer is "Yes")
Has applicant had any aircraft/aviation losses, claims or incidents during the last five years?

-Part 135 Only
Do you operate under your own P135 Certificate?
If No, do you have an aircraft lease and managing agreement in place with a P135 Operator?
If Yes, name of Operator:
How long have you been a P135 Operation?
Who manages the business/operation and for how long?
What is your target market?
What are your normal areas of operation/territory?

PILOT INFORMATION
Pilot 1

Pilot 1 Name: Birthdate:
Phone: Email:
Last FAA Medical: Class: Last Biennial Flight Review (BFR):
FAA Pilot Certificate(s):
Private
Commercial
ATP
CFI
CFII
MEI

FAA Pilot Rating(s):
ASEL
ASMEL
Instrument
ASES
AMES
Rotor-Helicopter

Total Logged Hours as Pilot:
Total Logged Hours in Retractable Gear:
Total Logged Hours in Multi-Engine:
Total Logged Hours in Turboprop:
Total Logged Hours in Turbojet:
Total Logged Hours in Make & Model:
Total Logged Hours Last 90 Days:
Type Rated in the Following Aircraft:
Please List Ground/Flight Training Programs Attended Within the Last 24 Months:
Name of School/Program: Date Attended: Aircraft: Initial Recurrent Simulator Based

BACKGROUND INFORMATION

(Please explain if the answer is "Yes")
Have you ever been involved in an aircraft accident or incident?
Do you have any convictions, suspensions, or revocations relating to a driver's license or airman's certificate for FAR violations, use or possession of controlled substances or driving while intoxicated?

If yes, please explain:

Pilot 2

Pilot 2 Name: Birthdate:
Phone: Email:
Last FAA Medical: Class: Last Biennial Flight Review (BFR):
FAA Pilot Certificate(s):
Private
Commercial
ATP
CFI
CFII
MEI

FAA Pilot Rating(s):
ASEL
ASMEL
Instrument
ASES
AMES
Rotor-Helicopter

Total Logged Hours as Pilot:
Total Logged Hours in Retractable Gear:
Total Logged Hours in Multi-Engine:
Total Logged Hours in Turboprop:
Total Logged Hours in Turbojet:
Total Logged Hours in Make & Model:
Total Logged Hours Last 90 Days:
Type Rated in the Following Aircraft:
Please List Ground/Flight Training Programs Attended Within the Last 24 Months:
Name of School/Program: Date Attended: Aircraft: Initial Recurrent Simulator Based

BACKGROUND INFORMATION

(Please explain if the answer is "Yes")
Have you ever been involved in an aircraft accident or incident?
Do you have any convictions, suspensions, or revocations relating to a driver's license or airman's certificate for FAR violations, use or possession of controlled substances or driving while intoxicated?

If yes, please explain: