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Primary Insured Information

How were you referred to us?

Primary Named Insured Type

Person

Business

Primary Insured Name*

First Last

Business Name*

Entity Type*

Phone*

Can we text you?

Yes

Email*

Primary Insured Address*

Street Address Address Line 2 City State ZIP Code

Primary Insured Occupation*

General Information

Effective Date for Policy*

MM slash DD slash YYYY

Select Policy Type*

New Insurance Policy

Renewal Policy

Airport*

Current Insurance Company (if any)

AOPA Membership?*

Yes

AOPA Membership #*

Aircraft Information

1. Aircraft Year*

1. Aircraft Make*

1. Aircraft Model*

1. Aircraft # of Seats*

1. Aircraft Insured Value*

1. Aircraft Liability Limit*

1. FAA #*

1. Aircraft Base (Airport ID)

1. Estimated Flight Hours

(next 12 month)

1. Hangared*

Yes

1. Tie Down*

Yes

Purpose and Use

1. Use of Aircraft

Pleasure

Business

Corporate Executive (flown by professional pilots)

1. Aircraft is used for

Flying Club

Photography

Sightseeing

Patrol Flights

Agriculture

Air Ambulance

Other

None

Other use of aircraft

1. Do aircraft carry passengers for hire or engage in any other operations for which a charge is made, or reimbursement is received?

Yes

1. Areas of Aircraft Operation*

(check all that apply)

USA

Canada

Mexico

Caribbean

Other

Other Area(s) Used*

1. Will the aircraft normally be operated from paved, public airports?

Yes

1. If no, please explain

1. Are flights made to U.S. Military Installations?

Yes

1. Does the aircraft have a “Standard” Airworthiness certificate in full force and effect?

Yes

1. If no, please explain

1. Has the applicant signed any agreements or contracts with respect to aircraft operations?

If “Yes,” please attach copies (e.g. hangar, maintenance, engine rental agreements, etc.).

Yes

Add a 2nd Aircraft?

Yes

2nd Aircraft Information

2. Aircraft Year*

2. Aircraft Make*

2. Aircraft Model*

2. Aircraft # of Seats*

2. Aircraft Insured Value*

2. Aircraft Liability Limit*

2. FAA #*

2. Aircraft Base (Airport ID)

2. Estimated Flight Hours

(next 12 month)

2. Hangared*

Yes

2. Tie Down*

Yes

Purpose and Use

2. Use of Aircraft

Pleasure

Business

Corporate Executive (flown by professional pilots)

2. Aircraft is used for

Flying Club

Photography

Sightseeing

Patrol Flights

Agriculture

Air Ambulance

Other

None

Other use of aircraft

2. Do aircraft carry passengers for hire or engage in any other operations for which a charge is made, or reimbursement is received?

Yes

2. Areas of Aircraft Operation*

(check all that apply)

USA

Canada

Mexico

Caribbean

Other

Other Area(s) Used*

2. Will the aircraft normally be operated from paved, public airports?

Yes

2. If no, please explain

2. Are flights made to U.S. Military Installations?

Yes

2. Does the aircraft have a “Standard” Airworthiness certificate in full force and effect?

Yes

2. If no, please explain

2. Has the applicant signed any agreements or contracts with respect to aircraft operations?

If “Yes,” please attach copies (e.g. hangar, maintenance, engine rental agreements, etc.).

Yes

Add a 3rd Aircraft?

Yes

3rd Aircraft Information

3. Aircraft Year*

3. Aircraft Make*

3. Aircraft Model*

3. Aircraft # of Seats*

3. Aircraft Insured Value*

3. Aircraft Liability Limit*

3. FAA #*

3. Aircraft Base (Airport ID)

3. Estimated Flight Hours

(next 12 month)

3. Hangared*

Yes

3. Tie Down*

Yes

Purpose and Use

3. Use of Aircraft

Pleasure

Business

Corporate Executive (flown by professional pilots)

3. Aircraft is used for

Flying Club

Photography

Sightseeing

Patrol Flights

Agriculture

Air Ambulance

Other

None

Other use of aircraft

3. Do aircraft carry passengers for hire or engage in any other operations for which a charge is made, or reimbursement is received?

Yes

3. Areas of Aircraft Operation*

(check all that apply)

USA

Canada

Mexico

Caribbean

Other

Other Area(s) Used*

3. Will the aircraft normally be operated from paved, public airports?

Yes

3. If no, please explain

3. Are flights made to U.S. Military Installations?

Yes

3. Does the aircraft have a “Standard” Airworthiness certificate in full force and effect?

Yes

3. If no, please explain

3. Has the applicant signed any agreements or contracts with respect to aircraft operations?

If “Yes,” please attach copies (e.g. hangar, maintenance, engine rental agreements, etc.).

Yes

Add a 4th Aircraft?

Yes

4th Aircraft Information

4. Aircraft Year*

4. Aircraft Make*

4. Aircraft Model*

4. Aircraft # of Seats*

4. Aircraft Insured Value*

4. Aircraft Liability Limit*

4. FAA #*

4. Aircraft Base (Airport ID)

4. Estimated Flight Hours

(next 12 month)

4. Hangared*

Yes

4. Tie Down*

Yes

Purpose and Use

3. Use of Aircraft

Pleasure

Business

Corporate Executive (flown by professional pilots)

4. Aircraft is used for

Flying Club

Photography

Sightseeing

Patrol Flights

Agriculture

Air Ambulance

Other

None

Other use of aircraft

4. Do aircraft carry passengers for hire or engage in any other operations for which a charge is made, or reimbursement is received?

Yes

4. Areas of Aircraft Operation*

(check all that apply)

USA

Canada

Mexico

Caribbean

Other

Other Area(s) Used*

4. Will the aircraft normally be operated from paved, public airports?

Yes

4. If no, please explain

4. Are flights made to U.S. Military Installations?

Yes

4. Does the aircraft have a “Standard” Airworthiness certificate in full force and effect?

Yes

4. If no, please explain

4. Has the applicant signed any agreements or contracts with respect to aircraft operations?

If “Yes,” please attach copies (e.g. hangar, maintenance, engine rental agreements, etc.).

Yes

Add a 5th Aircraft?

Yes

5th Aircraft Information

5. Aircraft Year*

5. Aircraft Make*

5. Aircraft Model*

5. Aircraft # of Seats*

5. Aircraft Insured Value*

5. Aircraft Liability Limit*

5. FAA #*

5. Estimated Flight Hours

(next 12 month)

5. Aircraft Base (Airport ID)

5. Hangared*

Yes

5. Tie Down*

Yes

Purpose and Use

5. Use of Aircraft

Pleasure

Business

Corporate Executive (flown by professional pilots)

5. Aircraft is used for

Flying Club

Photography

Sightseeing

Patrol Flights

Agriculture

Air Ambulance

Other

None

Other use of aircraft

5. Do aircraft carry passengers for hire or engage in any other operations for which a charge is made, or reimbursement is received?

Yes

5. Areas of Aircraft Operation*

(check all that apply)

USA

Canada

Mexico

Caribbean

Other

Other Area(s) Used*

5. Will the aircraft normally be operated from paved, public airports?

Yes

5. If no, please explain

5. Are flights made to U.S. Military Installations?

Yes

5. Does the aircraft have a “Standard” Airworthiness certificate in full force and effect?

Yes

5. If no, please explain

5. Has the applicant signed any agreements or contracts with respect to aircraft operations?

If “Yes,” please attach copies (e.g. hangar, maintenance, engine rental agreements, etc.).

Yes

Non-Owned Aircraft

Do you anticipate renting or chartering of other aircraft by applicant or any employees, or any use of employee’s personal aircraft on behalf of applicant?

Yes

Describe purpose, types of aircraft used, and anticipated annual utilization.

Do you anticipate the use of temporary substitute aircraft during servicing or maintenance of insured aircraft?

Yes

Please describe purpose, types of aircraft used, and anticipated annual utilization

Pilot Information

1. Pilot Name

1. DOB

1. Date Employed

1. Airmen's Certificate No.

1. Phone

1. Email

1. Logged Hours: Total

1. Logged Hours: Last 12 Months

1. Logged Hours: Last 90 Days

1. Tailwind: Total

1. Tailwind: Last 12 Months

1. Tailwind: Last 90 Days

1. Single-Engine Piston: Total

1. Single-Engine Piston: Last 12 Months

1. Single-Engine Piston: Last 90 Days

1. Aerial Applicator: Total

1. Aerial Applicator: Last 12 Months

1. Aerial Applicator: Last 90 Days

1. Retractable Gear: Total

1. Retractable Gear: Last 12 Months

1. Retractable Gear: Last 90 Days

1. Multi-Engine: Total

1. Multi-Engine: Last 12 Months

1. Multi-Engine: Last 90 Days

1. Turboprop: Total

1. Turboprop: Last 12 Months

1. Turboprop: Last 90 Days

1. Pressurized: Total

1. Pressurized: Last 12 Months

1. Pressurized: Last 90 Days

1. Jet: Total

1. Jet: Last 12 Months

1. Jet: Last 90 Days

1. Rotorwing Piston: Total

1. Rotorwing Piston: Last 12 Months

1. Rotorwing Piston: Last 90 Days

1. Rotorwing Turbine: Total

1. Rotorwing Turbine: Last 12 Months

1. Rotorwing Turbine: Last 90 Days

1. Instrument: Total

1. Instrument: Last 12 Months

1. Instrument: Last 90 Days

1. Nighttime: Total

1. Nighttime: Last 12 Months

1. Nighttime: Last 90 Days

1. Sea: Total

1. Sea: Last 12 Months

1. Sea: Last 90 Days

Pilot Logged Hours

1. Aircraft Model

1. Hours Total

1. Hours Last 12 Months

1. Hours Last 90 Days

Pilot Certificates and Ratings

1. Certificates and Ratings

(check all that apply)

Student

Private

Commercial

Airline Transport

Single Engine Land

Multi Engine Land

Single Engine Sea

Multi Engine Sea

Instrument

CFI

CFII

M.E. CFI

Glider

Lighter than Air

A&P Mechanic

Aircraft Inspector

Rotorwing

Other

1. Last Biennial Flight Review Date

MM slash DD slash YYYY

1. B.F.R. Model Used

Pilot Medical Certificate

Class

1st

2nd

3rd

1. Date of Last Physical

MM slash DD slash YYYY

1. Expiration Date

MM slash DD slash YYYY

Pilot Training

1. School Name and Location (1)

1. Month / Year Attended (1)

1. Aircraft Model (1)

1. School Name and Location (2)

1. Month / Year Attended (2)

1. Aircraft Model (2)

1. School Name and Location (3)

1. Month / Year Attended (3)

1. Aircraft Model (3)

Pilot Additional Information

1. As a pilot, any aircraft accidents, incidents, or claims?

Yes

1. Ever cited for violating civil or military flight regulations?

Yes

1. Ever convicted or pled guilty to a felony?

Yes

1. Ever arrested for driving under the influence of drugs/alcohol?

Yes

1. Any waivers or limitations on your Medical Certificate?

Yes

1. Any Insurance Company ever cancel, decline to lease or decline to renew any insurance policy held by you?

Yes

1. Explain any pilot question above answered

Add a 2nd Pilot?

Yes

2nd Pilot Information

2. Pilot Name

2. DOB

2. Date Employed

2. Airmen's Certificate No.

2. Phone

2. Email

2. Logged Hours: Total

2. Logged Hours: Last 12 Months

2. Logged Hours: Last 90 Days

2. Tailwind: Total

2. Tailwind: Last 12 Months

2. Tailwind: Last 90 Days

2. Single-Engine Piston: Total

2. Single-Engine Piston: Last 12 Months

2. Single-Engine Piston: Last 90 Days

2. Aerial Applicator: Total

2. Aerial Applicator: Last 12 Months

2. Aerial Applicator: Last 90 Days

2. Retractable Gear: Total

2. Retractable Gear: Last 12 Months

2. Retractable Gear: Last 90 Days

2. Multi-Engine: Total

2. Multi-Engine: Last 12 Months

2. Multi-Engine: Last 90 Days

2. Turboprop: Total

2. Turboprop: Last 12 Months

2. Turboprop: Last 90 Days

2. Pressurized: Total

2. Pressurized: Last 12 Months

2. Pressurized: Last 90 Days

2. Jet: Total

2. Jet: Last 12 Months

2. Jet: Last 90 Days

2. Rotorwing Piston: Total

2. Rotorwing Piston: Last 12 Months

2. Rotorwing Piston: Last 90 Days

2. Rotorwing Turbine: Total

2. Rotorwing Turbine: Last 12 Months

2. Rotorwing Turbine: Last 90 Days

2. Instrument: Total

2. Instrument: Last 12 Months

2. Instrument: Last 90 Days

2. Nighttime: Total

2. Nighttime: Last 12 Months

2. Nighttime: Last 90 Days

2. Sea: Total

2. Sea: Last 12 Months

2. Sea: Last 90 Days

Pilot Logged Hours

2. Aircraft Model

2. Hours Total

2. Hours Last 12 Months

2. Hours Last 90 Days

Pilot Certificates and Ratings

2. Certificates and Ratings

(check all that apply)

Student

Private

Commercial

Airline Transport

Single Engine Land

Multi Engine Land

Single Engine Sea

Multi Engine Sea

Instrument

CFI

CFII

M.E. CFI

Glider

Lighter than Air

A&P Mechanic

Aircraft Inspector

Rotorwing

Other

2. Last Biennial Flight Review Date

MM slash DD slash YYYY

2. B.F.R. Model Used

Pilot Medical Certificate

Class

1st

2nd

3rd

2. Date of Last Physical

MM slash DD slash YYYY

2. Expiration Date

MM slash DD slash YYYY

Pilot Training

2. School Name and Location (1)

2. Month / Year Attended (1)

2. Aircraft Model (1)

2. School Name and Location (2)

2. Month / Year Attended (2)

2. Aircraft Model (2)

2. School Name and Location (3)

2. Month / Year Attended (3)

2. Aircraft Model (3)

Pilot Additional Information

2. As a pilot, any aircraft accidents, incidents, or claims?

Yes

2. Ever cited for violating civil or military flight regulations?

Yes

2. Ever convicted or pled guilty to a felony?

Yes

2. Ever arrested for driving under the influence of drugs/alcohol?

Yes

2. Any waivers or limitations on your Medical Certificate?

Yes

2. Any Insurance Company ever cancel, decline to lease or decline to renew any insurance policy held by you?

Yes

2. Explain any pilot question above answered

Add a 3rd Pilot?

Yes

3rd Pilot Information

3. Pilot Name

3. DOB

3. Date Employed

3. Airmen's Certificate No.

3. Phone

3. Email

3. Logged Hours: Total

3. Logged Hours: Last 12 Months

3. Logged Hours: Last 90 Days

3. Tailwind: Total

3. Tailwind: Last 12 Months

3. Tailwind: Last 90 Days

3. Single-Engine Piston: Total

3. Single-Engine Piston: Last 12 Months

3. Single-Engine Piston: Last 90 Days

3. Aerial Applicator: Total

3. Aerial Applicator: Last 12 Months

3. Aerial Applicator: Last 90 Days

3. Retractable Gear: Total

3. Retractable Gear: Last 12 Months

3. Retractable Gear: Last 90 Days

3. Multi-Engine: Total

3. Multi-Engine: Last 12 Months

3. Multi-Engine: Last 90 Days

3. Turboprop: Total

3. Turboprop: Last 12 Months

3. Turboprop: Last 90 Days

3. Pressurized: Total

3. Pressurized: Last 12 Months

3. Pressurized: Last 90 Days

3. Jet: Total

3. Jet: Last 12 Months

3. Jet: Last 90 Days

3. Rotorwing Piston: Total

3. Rotorwing Piston: Last 12 Months

3. Rotorwing Piston: Last 90 Days

3. Rotorwing Turbine: Total

3. Rotorwing Turbine: Last 12 Months

3. Rotorwing Turbine: Last 90 Days

3. Instrument: Total

3. Instrument: Last 12 Months

3. Instrument: Last 90 Days

3. Nighttime: Total

3. Nighttime: Last 12 Months

3. Nighttime: Last 90 Days

3. Sea: Total

3. Sea: Last 12 Months

3. Sea: Last 90 Days

Pilot Logged Hours

3. Aircraft Model

3. Hours Total

3. Hours Last 12 Months

3. Hours Last 90 Days

Pilot Certificates and Ratings

3. Certificates and Ratings

(check all that apply)

Student

Private

Commercial

Airline Transport

Single Engine Land

Multi Engine Land

Single Engine Sea

Multi Engine Sea

Instrument

CFI

CFII

M.E. CFI

Glider

Lighter than Air

A&P Mechanic

Aircraft Inspector

Rotorwing

Other

3. Last Biennial Flight Review Date

MM slash DD slash YYYY

3. B.F.R. Model Used

Pilot Medical Certificate

Class

1st

2nd

3rd

3. Date of Last Physical

MM slash DD slash YYYY

3. Expiration Date

MM slash DD slash YYYY

Pilot Training

3. School Name and Location (1)

3. Month / Year Attended (1)

3. Aircraft Model (1)

3. School Name and Location (2)

3. Month / Year Attended (2)

3. Aircraft Model (2)

3. School Name and Location (3)

3. Month / Year Attended (3)

3. Aircraft Model (3)

Pilot Additional Information

3. As a pilot, any aircraft accidents, incidents, or claims?

Yes

3. Ever cited for violating civil or military flight regulations?

Yes

3. Ever convicted or pled guilty to a felony?

Yes

3. Ever arrested for driving under the influence of drugs/alcohol?

Yes

3. Any waivers or limitations on your Medical Certificate?

Yes

3. Any Insurance Company ever cancel, decline to lease or decline to renew any insurance policy held by you?

Yes

3. Explain any pilot question above answered

Additional Information

Has the insurer ever canceled or non-renewed any aviation insurance policy?

Yes

Have the pilot(s) ever been cited or fined for violation of an aviation regulation?

Yes

Has the pilot(s) certificate ever been suspended or revoked?

Yes

Have the pilot(s) ever been convicted of a felony or are you under indictment for a felony?

Yes

Have the pilot(s) ever been convicted of driving a motor vehicle under the influence of alcohol, narcotics, or of reckless driving?

Yes

Has the pilot(s) driver’s license ever been suspended or revoked?

Yes

Have the Pilot(s) ever been treated for a chemical dependency?

Yes

Are there any physical impairments or limitations or waivers on the pilot(s) Medical Certificate?

Yes

Has the insured or any pilot(s) ever had an aircraft claim, incident or accident in the past 5 years?

Yes

If you answered “Yes” to any of the above questions, please provide more details below.

Additional Interests

e.g. Banks, Additional Insureds, Lessors, etc.

Add Additional Interest

Yes

1. Aircraft

1. Certificate Required

Yes

1. Additional Interest

1. Nature of Interest

Add 2nd Additional Interest

Yes

2. Aircraft

2. Certificate Required

Yes

2. Additional Interest

2. Nature of Interest

Add 3rd Additional Interest

Yes

3. Aircraft

3. Certificate Required

Yes

3. Additional Interest

3. Nature of Interest

Add 4th Additional Interest

Yes

4. Aircraft

4. Certificate Required

Yes

4. Additional Interest

4. Nature of Interest

Add 5th Additional Interest

Yes

5. Aircraft

5. Certificate Required

Yes

5. Additional Interest

5. Nature of Interest

Additional Comments

Documents

Drop files here or

Max. file size: 20 MB.

Consent*

All the information herein is true and correct to the best of my knowledge and I have not knowingly or intentionally concealed or misrepresented any fact. This form will become part of the insurance application and as such all fraud statements are applicable.

I agree.

Signature*

Date

MM slash DD slash YYYY

View Insurance Fraud Statement

Personal Insurance

Business Insurance

Personal Insurance

Business Insurance

Personal Account Review

Business Account Review

For Clients

Aviation Insurance Quote

Primary Insured Information

General Information

Aircraft Information

Purpose and Use

2nd Aircraft Information

Purpose and Use

3rd Aircraft Information

Purpose and Use

4th Aircraft Information

Purpose and Use

5th Aircraft Information

Purpose and Use

Non-Owned Aircraft

Pilot Information

Pilot Logged Hours

Pilot Certificates and Ratings

Pilot Medical Certificate

Pilot Training

Pilot Additional Information

2nd Pilot Information

Pilot Logged Hours

Pilot Certificates and Ratings

Pilot Medical Certificate

Pilot Training

Pilot Additional Information

3rd Pilot Information

Pilot Logged Hours

Pilot Certificates and Ratings

Pilot Medical Certificate

Pilot Training

Pilot Additional Information

Additional Information

Additional Interests

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