First Name:*Last Name:*Telephone:*Email:* Name of Person or Entity to Be Insured*City*State*Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingEffective Date MM slash DD slash YYYY Aircraft Make & Model:*Tail #:Home Airport:*How is the aircraft stored:* Hangared Tied DownTotal Seating Capacity*Use of Aircraft:*Please Select One Or More Of The Following Select All Pleasure & Business Charter Sightseeing Instruction & Rental Aerial PhotographyAircraft Make & Model:Tail #:Home Airport:How is the aircraft stored: Hangared Tied DownTotal Seating CapacityUse of Aircraft:Please Select One Or More Of The Following Select All Pleasure & Business Charter Sightseeing Instruction & Rental Aerial PhotographyHull Value:*Add Another Aircraft?* Yes NoLiability Limit:* $1 Million/$100,000 $1 Million/$200,000 $1 Million smooth $2 Million smooth Pilot Name:*Pilot Age:*Pilot Ratings:* Sport Private Instrument Commerical ATP Multi-Engine CFI SeaplanePilot's Total Logged Flying Hours:*Total Tailwheel Hours:Total Retractable Gear Hours:Total Multiengine Hours:Pilot's Total Hours Logged In The Last 12 Months:*Total Hours Logged In Insured Make and Model:Any Prior FAA Violations?* Yes NoIf Yes, Please Explain:Add Another Pilot* Yes NoPilot Name:Pilot Age:Pilot Ratings: Sport Private Instrument Commerical ATP Multi-Engine CFI SeaplanePilot's Total Logged Flying Hours:Total Tailwheel Hours:Total Retractable Gear Hours:Total Multiengine Hours:Pilot's Total Hours Logged In The Last 12 Months:Total Hours Logged In Insured Make and Model:Any Prior FAA Violations? Yes NoIf Yes, Please Explain:Any Insurance Claims In The Past 5 Years?* Yes NoIf Yes, Please Provide Claim Details:Additional Comments/Questions:
