Aircraft Insurance Form

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?

Yes
No

What date is coverage needed?

Aircraft Information

What is the year, make and model of the aircraft?

Year	Make	Model

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:

Private Airport
Public Airport

Are the runways paved?

Yes
No

Are any flights contemplated outside the continental U.S.?

Yes
No

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.

First Name	Last Name

Please describe the special/other uses of this aircraft:

Ownership Information

Who is applying for the insurance for this aircraft?

Sole Owner
Owner Subject to Mortgage or Conditional Sales Contract
Lessee

What type of entity is the owner of this aircraft?

Individual
Corporation
Limited Liability Corporation
Co-Ownership/Partnership

Is this aircraft encumbered by a mortgage or other lien?

Yes
No

What is the mortgage, lien holder, or lessor's name?

What is the mortgage, lien holder, or lessor's address?

Street Address Address Line 2 City State ZIP Code

What is the amount of the mortgage or lien?

Will lien holder's interest be required by the lien holder?

Yes
No

Pilot Information

Please enter the pilot(s) information below.

Pilot's Name	Pilot's Age

Supplemental Questions

Does the aircraft have OTHER than a standard airworthiness certificate in full effect?

Yes
No

Please explain:

Are there any other aircraft owned by the applicant?

Yes
No

Please explain:

Has the aircraft been equipped with modifications not provided by the manufacturer?

Yes
No

Please explain:

Will the aircraft be normally operated in OTHER than paved public airports?

Yes
No

Please explain:

Will anyone else other than those already listed on this form have use of the aircraft?

Yes
No

Please explain:

Will the aircraft be used for any purpose(s) for which a charge is made?

Yes
No

Please explain:

Is there any un-repaired damage to the aircraft?

Yes
No

Please explain:

Has the applicant or any pilot listed in the "Pilot Information" Section of this application ever been involved in any aircraft accident?

Yes
No

Please explain:

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?

Yes
No

Please explain:

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?

Yes
No

Please explain:

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?

Yes
No

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?

Yes
No

Please explain:

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)

$500,000 each Accident and/or Occurrence / $100,000 Bodily Injury Insurance, Each Passenger
$1,000,000 each Accident and/or Occurrence / $100,000 Bodily Injury Insurance, Each Passenger
$1,000,000 each Accident and/or Occurrence / $200,000 Bodily Injury Insurance, Each Passenger
$1,000,000 each Accident and/or Occurrence / No Sublimit for Bodily Injury Insurance, Each Passenger
$2,000,000 each Accident and/or Occurrence / $200,000 Bodily Injury Insurance, Each Passenger
$2,000,000 each Accident and/or Occurrence / No Sublimit for Bodily Injury Insurance, Each Passenger
Other Liability Limit

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:

$3,000
$5,000
$10,000
Other

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...)

Drop files here or

Max. file size: 128 MB, Max. files: 5.

Please enter any additional remarks in the space below.

How did you hear about us?

Please share who referred you to us.

Can you share what you typed into Google?

Please let us know how you heard about us.

Consent*

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.

I agree

Aircraft Insurance Form

Aircraft Information

Usage and Operation Information

Ownership Information

Pilot Information

Supplemental Questions

Coverages and Limits

Documents and Comments

Kurt Thoennessen, CAPI

RiskRevu^TM Newsletter

Contact

Aircraft Insurance Form

Aircraft Information

Usage and Operation Information

Ownership Information

Pilot Information

Supplemental Questions

Coverages and Limits

Documents and Comments

Kurt Thoennessen, CAPI

Share This

RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter