What is your first name?
What is your last name?
What is your email address?
What is your preferred phone number?
Is there aircraft insurance in place?
What date is coverage needed?
MM slash DD slash YYYY
What is the year, make and model of the aircraft?
What is the FAA number for this aircraft?
What is the engine horsepower of this aircraft?
How many seats are there for the crew?
How many seats are there for the passengers?
What is the name of the airport where the aircraft is usually based?
What is the airport I.D./identifier?
Please select the airport type:
Are the runways paved?
Are any flights contemplated outside the continental U.S.?
Where will the aircraft fly to outside the continental U.S.?
What is the current value of the aircraft?
Usage and Operation Information
How is this aircraft used?
Please list the name(s) of the student(s) and/or pilot(s) being trained.
Please describe the special/other uses of this aircraft:
Who is applying for the insurance for this aircraft?
What type of entity is the owner of this aircraft?
Is this aircraft encumbered by a mortgage or other lien?
What is the mortgage, lien holder, or lessor's name?
What is the mortgage, lien holder, or lessor's address?
What is the amount of the mortgage or lien?
Will lien holder's interest be required by the lien holder?
Please enter the pilot(s) information below.
Does the aircraft have OTHER than a standard airworthiness certificate in full effect?
Are there any other aircraft owned by the applicant?
Has the aircraft been equipped with modifications not provided by the manufacturer?
Will the aircraft be normally operated in OTHER than paved public airports?
Will anyone else other than those already listed on this form have use of the aircraft?
Will the aircraft be used for any purpose(s) for which a charge is made?
Is there any un-repaired damage to the aircraft?
Has the applicant or any pilot listed in the "Pilot Information" Section of this application ever been involved in any aircraft accident?
Has the applicant or any pilot listed in the "Pilot Information" Section of this application ever been cited for a violation of any aviation regulation in any country?
Has the applicant or any pilot listed in the "Pilot Information" Section of this application ever had an FAA, Military, or other pilot certificate suspended or revoked?
Does the applicant or any pilot listed in the "Pilot Information" Section of this application have any; (a) physical impairment, (b) waivers, limitations, conditions on their medical certificates or on their airman certificates?
Please provide an explanation regarding physical impairments or waivers, limitations, or conditions on medical or airman certificates:
Has the applicant or any pilot listed in the "Pilot Information" Section of this application ever been convicted of or plead guilty to a felony, possession or drugs, or of driving while intoxicated?
Coverages and Limits
What is the current value of the aircraft? (Ex. $750,000)
What is the current deductible?
Please select the desired liability limit quotes you would like for this aircraft: (Select all that apply)
Please specify the liability limits you would like for this aircraft policy:
Please select the medical payments including crew limits you would like for this aircraft insurance policy:
Please enter the limit you would like for Medical Payments Including Crew coverage.
Documents and Comments
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, etc...)
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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.