Aircraft Insurance Quote Form

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or you may fill in the information, print the form from your browser window by clicking on the Printable Version button above, and mail or fax the form to:
Company Name, Street Address, City, State, Zip Code
Fax Number

* Denotes Required Field

Personal Information
*Name:
*Address:
*City:	*State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming   *Zip Code:
*Day Phone:	*Evening Phone:   Ex. 920-555-1212
Best Time to Call:	Select One Morning (8 a.m.-noon) Afternoon (noon-5 p.m.) Evening (5 p.m.-9 p.m.)
*Contact E-Mail Address:
*Confirm E-Mail Address:

General Information
Marital Status:	Select One Married Single Divorced Separated Widowed
Occupation:
Employer:
Time at Current Employer:
Social Security Number:	Ex. 444-55-6666
Airman's Certificate Number:
Automobile Driver's License Number:
Issuing State:	Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming

Certificates and Ratings
Certificates Attained (check all that apply):	Student Recreational Private Commercial ATP	Instructor IFR Instructor ME Instructor Single-Engine Land Multi-Engine Land	Single-Engine Sea Multi-Engine Sea Helicopter Glider Instrument Rating
Type Ratings:
Medical Date:	Ex. 01/15/2004
Medical Class:	Select One I II III
Flight Review Date:	Ex. 01/15/2004
Flight Review Completed In (list aircraft type):

Total Logged Pilot Hours
TOTAL TIME:		Rotor Wing:
Pilot in Command:		Turbine Rotor Wing:
Second in Command:		Total Aerial Application:
Flight Engineer:		War Bird:
Multi-Engine Land:		Total Seaplane:
Instrument (both actual and simulated):		Multi-Engine Seaplane:
Turbo Jet:		Single-Engine Turbo Prop:
Turbo Prop:		All Aircraft - Last 90 Days:
Retractable Gear:		All Aircraft - Last 12 Months:
Conventional Gear (tail wheel):		Other:
		If "Other," please describe:

Applicant Requests Approval in the Following Aircraft
Total Logged Hours in the same make/model of aircraft insured	Last 12 Months	Is Annual Recurrent Training Received in this Aircraft?
		Select One Yes No	Where:	When:
		Select One Yes No	Where:	When:
		Select One Yes No	Where:	When:

Questions
Do you hold a current FSI Pro Card or Simuflite Card?:	Select One Yes No
Do you participate in the FAA pilot proficiency award program?:	Select One Yes No
If "Yes," please list the highest phase completed:
If "Yes," for which type of aircraft?:
Please list refresher/transition courses. Describe and give the dates of the last course attended:
Are you flying under a medical waiver?:	Select One Yes No
Have you ever had an aircraft accident/incident or been penalized for an FAR violation?:	Select One Yes No
Has any insurance company or underwrited cancelled, declined, or refused to renew any insurance on your behalf?:	Select One Yes No
Have you ever been convicted of driving a motor vehicle while under the influence of alcohol or narcotics or of reckless driving?:	Select One Yes No
Has you driver's license ever been suspended or revoked?:	Select One Yes No
Have you ever been convicted of any, or are you under indictment in a legal action related to any, drug or narcotic violations?:	Select One Yes No
I WARRANT that the answers given are true and complete to the best of my knowledge and believe that no material information has been withheld or suppressed.

Additional Pilots
Pilot #1 Name:
Pilot #2 Name:
Pilot #3 Name:
Pilot #4 Name:
Pilot #5 Name:

Aircraft Information
FAA Registration Number:		Year:
Make:		Model:
Total Seats:		Airframe Hours:
Last Annual:	Ex. 01/15/2004	Engine Hours SMOH (each side if multi-engine):
Is the aircraft ever converted to floats or skis?:	Select One Yes No
Base Airport Name/Identifier:		Base Airport City:
If base airport is private, what is the length of the longest runway?:	feet	Base Airport State:	Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
If base airport is private, are the runways paved?:	Select One Yes No	How is the aircraft stored?:	Select One Hangared Tied Out
Is there a lien holder on the aircraft?:	Select One Yes No	Lien Holder:

Choose Your Coverage
Do you want hull coverage?:	Select One Yes No
If "Yes," what is the current retail value of your aircraft?: $
Hull Coverage Desired:	Select One Ground and Flight
What liability limits would you like?:	Select One $1 million each occurrence, limited to $100,000 each passenger

Additional Questions
Do any of the listed pilots participate in the FAA pilot proficiency award program?:	Select One Yes No
If "Yes," what is the highest phase completed?:
If "Yes," for which type of aircraft?:
Do you receive annual training in the aircraft insured?:	Select One Yes No
If "Yes," where and when was the recurrent training received?:
Does the aircraft have other than a "standard" airworthiness certificate in effect?:	Select One Yes No
Are there any other aircraft owned by the applicant?:	Select One Yes No
Has the aircraft been equipped with mods not provided by the original aircraft manufacturer?:	Select One Yes No
If "Yes," please explain:
Do you anticipate aircraft to be operated outside the continental United States?:	Select One Yes No
If "Yes," where?:
Will aircraft be normally operated from other than paved public airports?:	Select One Yes No
If "Yes," where?:
Will aircraft be used for student/pilot instruction other than for recurrent training of pilots listed on this application?:	Select One Yes No
Will anyone other than the applicant and pilots listed have use of the aircraft?:	Select One Yes No
Will aircraft be used for any purpose(s) for which a charge is made?:	Select One Yes No
Is there any unprepared damage to the aircraft?:	Select One Yes No
Has the applicant had any aircraft/aviation insurance claims/losses/accidents/incidents?:	Select One Yes No
Has any insurer cancelled, declined, or refused to renew any aviation insurance for the applicant?:	Select One Yes No
Do any of the pilots named have any physical impairments, waivers, statements of demonstrated ability (other than corrective lenses), limitations, or conditions attached to their medical certificate?:	Select One Yes No
Has any pilot named had any convictions, suspensions, or revocations for FAR violations, use of drugs, reckless driving, or driving under the influence of alcohol?:	Select One Yes No
If "Yes," please explain:
Has any pilot named ever been involved in any aircraft accident or incident?:	Select One Yes No

Additional Comments

Please provide any additional comments that you feel would be appropriate for this quotation. If you have additional information to provide, where there were not enough fields above, such as additional drivers, vehicles, driver histories, etc., please enter it here

*Acknowledgment & Consent

I hereby certify that the above information is complete and accurate to the best of my knowledge. I hereby authorize the agency to obtain motor vehicle reports, loss reports and credit reports about me on an ongoing basis during this quotation and policy period and to check my motor vehicle and driving record on an ongoing basis during the term of the determination and policy period. The agency receiving this application will retain the application whether or not a policy is issued. The agency may rely on this application when determining the quotation and when deciding whether to issue a policy. False statements may subject me to criminal penalties. I authorize the agency to obtain a motor vehicle and driving record about me on an ongoing basis during this quotation and policy period and to check my motor vehicle and driving record on an ongoing basis during the term of the determination and policy period. If a policy is issued, I authorize the agency to give information about me to its affiliates. Yes No Enter your initials here:   Today's date: Ex. 01/15/2004

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