Provide the following information to procure a fast aircraft insurance quote.  The fields can be navigated simply by pressing the tab key to allow for easy input of information.  Please enter all applicable information to allow us to provide you with the most competitive quote.  Pilot #2 information is only required if more than one pilot is to be named on the insurance  policy.  Please review the form for accuracy before pressing the submit button.  Pressing the submit button will email the information provided and we will begin work on your quote immediately.  All information provided is done so in strictest confidence and will be used only for the purposes of obtaining your insurance quote and for contacting you.  No information will be given or shared with anyone except in pursuing your personal quote.

APPLICANT INFORMATION                       
First Name
Last Name
Address
City
State Zip
Work #   Home #
Fax #   Email
Occupation

Present Insurance Carrier /Indicate If New Or Prospective Purchase
Insurance Expiration Date
Are You A Member of AOPA Yes No 
If Yes, AOPA Member Number
Are You A Member Of EAA  Yes No
If Yes, EAA Member Number
Has the applicant had any aviation related losses/incidents (claims) in the past 5 years?  Yes   No
If yes was answered to the question above, please give details to include dates, type of loss/incident, amount paid, etc.

 
AIRCRAFT INFORMATION
FAA #   Make
Model   Year  
Seats ( including pilot )
Insured Value
Base Airport Location
Base Airport ID
Aircraft Is
Landing Gear Is
Aircraft Use(s)
Lien Holder Name
Lien Amount
Last Annual
Does The Applicant Own Any Additional Aircraft  Yes  No

Coverages Requested---Liability Limits
$ 500,000 Combined Single Limit-Passengers Limited to $100,000
$1,000,000 Combined Single Limit-Passengers limited to $100,000
$1,000,000 Combined Single Limit-No Separate Passenger Sub-Limits
Other(Specify)
Medical Coverage Each Passenger

 

PILOT #1    INFORMATION
Pilot #1 Full Name
Date of Birth
Current Employer
Date of last Biennial Flight Review
Airman's Certificate Number
Have You Attended Any Formal Ground & Flight Or Simulator Training For The Requested Make & Model Aircraft ? YES  NO

IF Yes, Please Indicate Specifics Of Training, Where Attended, and Date Last  Completed.

Check Any of the Following Certification and Ratings That Apply
Student Private Commercial
Airline Transport(ATP) Instructor(CFI)
Instrument Instructor(CFII) Rotorwing Instructor
Multi Engine Instructor(MEI) Instrument Rating
Single Engine Land Multi Engine Land
Seaplane Multi Engine Sea Rotorwing
Center Line Thrust Glider
Mechanic, Aircraft and Power Plant
Type Ratings & Endorsements(Specify)
Type Medical & Expiration Date
Pilot #1  Aircraft Hours
Total Logged Hours   Multi Engine Hours
Single Engine Retract Hours   Tailwheel Hours
Turbo Prop Hours   Turbo Jet Hours  
Rotorwing Hours   Seaplane/Amphibian Hours
Total Logged Hours In Make & Model  
Total Logged Hours In Make & Model Last 90 Days
Total Logged Hours In Make & Model Last 12 Months  
Total Logged Hours In All Aircraft Last 90 Days
Total Logged Hours In All Aircraft Last 12 Months
PLEASE EXPLAIN ANY YES ANSWERS TO THE FOLLOWING QUESTIONS IN THE SPACE PROVIDED BELOW.
1. Do you have any physical condition(s), limitation(s) or impairment(s) that require a waiver or special condition to be attached or indicated on your Medical Certificate?  YES NO
2. Has your FAA or DOT or Military Pilot Certificate ever been suspended or revoked?  YES NO
3. Have you ever been cited for any violations of Federal or Canadian Air Regulations or have limitations ever been placed on your Pilot Certificate?     YES NO
4. Arising out of the operation of a Motor Vehicle, have you had your driver's license suspended or revoked during the past 5 years?   YES NO
5. Have you been convicted or pleaded guilty to a charge of reckless driving or driving under the influence of alcohol or drugs during the past 5 years?        YES NO
6. Have you ever had an application for Aircraft Hull or Liability insurance declined by an insurance company? (Question #6 not applicable in states where prohibited by law )           YES NO
7. Have you ever had any aircraft accidents or incidents while acting as Pilot within the past five years? [If "Yes", give dates, places, make and model of aircraft and details of Accidents/Incidents]  
 YES  NO

Explanations Below
PILOT #2  INFORMATION  (only required if there is to be more than one named pilot)
Pilot #2 Full Name
Date of Birth
Current Employer
Date of last Biennial Flight Review
Airman's Certificate Number

Check Any of the Following Certification and Ratings That Apply
Student Private Commercial
Airline Transport(ATP) Instructor(CFI)
Instrument Instructor(CFII) Rotorwing Instructor
Multi Engine Instructor(MEI) Instrument Rating
Single Engine Land Multi Engine Land
Seaplane Multi Engine Sea Rotorwing
Center Line Thrust Glider
Mechanic, Aircraft and Power Plant
Type Ratings & Endorsements(Specify)
Pilot #2  Aircraft Hours
Total Hours Multi Engine Hours
Single Engine Retract Hours   Tailwheel Hours
Total Logged Hours In Make & Model  
Total Logged Hours In Make & Model Last 90 Days
Total Logged Hours In Make & Model Last 12 Months  
Total Logged Hours In All Aircraft Last 90 Days
Total Logged Hours In All Aircraft Last 12 Months
PLEASE EXPLAIN ANY YES ANSWERS TO THE FOLLOWING QUESTIONS IN THE SPACE PROVIDED.
1. Do you have any physical condition(s), limitation(s) or impairment(s) that require a waiver or special condition to be attached or indicated on your Medical Certificate?  YES NO
2. Has your FAA or DOT or Military Pilot Certificate ever been suspended or revoked?  YES NO
3. Have you ever been cited for any violations of Federal or Canadian Air Regulations or have limitations ever been placed on your Pilot Certificate?     YES NO
4. Arising out of the operation of a Motor Vehicle, have you had your driver's license suspended or revoked during the past 5 years?   YES NO
5. Have you been convicted or pleaded guilty to a charge of reckless driving or driving under the influence of alcohol or drugs during the past 5 years?        YES NO
6. Have you ever had an application for Aircraft Hull or Liability insurance declined by an insurance company? (Question #6 not applicable in states where prohibited by law )           YES NO
7. Have you ever had any aircraft accidents or incidents while acting as Pilot within the past five years? [If "Yes", give dates, places, make and model of aircraft and details of Accidents/Incidents]
  YES  NO

Explanations Below
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