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AIRCRAFT INSURANCE APPLICATION
1. INSURED INFORMATION
 
Name Of Applicant
Address
City
State
Zip
Phone
Email
(Email address is required)
Business Of Applicant
Insurance Requested From
TO
Purpose Of Use
Applicant is
Owner
Lessee
   
   
2. AIRCRAFT INFORMATION  
   
Make And Model
Year
FAA N#
Seating Capacity
Purchase Date
Approximate Engine Hours
Since New or SMOH
Agreed Hull Value
Aircraft Liability
Smooth CSL Limit
Aircraft Liability Including Passenger Sub-Limit
   
Is aircraft operational and
Air Worthiness Certificate
in full force and in effect?
Yes
No
         
Is the aircraft operated
under a FAA Standard
Air Worthiness Certificate?
Yes
No
Explain All 'No' Answers
 
Has aircraft and/or
engines been modified?
Yes
No
         
Is there any unrepaired
damage to the aircraft?
Yes
No
Explain All 'Yes' Answers
   
Please list Bank or Lienholder information if aircraft is mortgaged or encumbered
Approximate Loan Balance/Amount of mortgage
   
   
3. AIRCRAFT OPERATION  
   
Number of Hours aircraft was flown in the past 12 months
   
Estimated hours to fly in the next 12 months
 
Aircraft is
Hangared
Tied-Down
 
Airport
City
State
   
Type of Airport
Public Airport
Private Airport
Tower
Yes
No
Runway Paved
Yes
No
   
Will aircraft be operated
at other than paved
public airports?
Yes
No
         
Will aircraft be operated
outside the 48 contiguous
states of USA?
Yes
No
         
How frequently does an applicant use non-owned aircraft?
   
Will aircraft be used for
student or pilot instruction?
Yes
No
         
Has applicant had any aircraft/aviation losses,
claims or incidents
during the last 5 years?
Yes
No
         
Has any insurer cancelled, declined, sent notice of cancellation, or refused to renew any aviation insurance?
Yes
No
         
Please explain each 'Yes' Answer
   
   
Pilot's Signature
(Electronic signature is required)
  I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license. I understand that an electronic signature shall have the same force and effect as a written signature.
   
Date
(Submission date is required)
   
 
   
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