Your Name:

Email Address:

Mailing Address:

City: State: Arizona Illinois Indiana Iowa Kansas Minnesota Wisconsin Zip:

Phone Number w/ area code:

Present insurance co:

Expiration Date (XX/XX/XX):

AIRCRAFT INFORMATION

Aircraft Year, Make, Model:

Aircraft Base:

Hangared or Tied-Out:

"N" Number Total seats:

Airplane used for:
Pleasure and Business

Other

AIRCRAFT COVERAGES

Hull Coverage: Insured Value:

Ground and Taxi Ground and Flight Ground Only None

Limits of Liability:

$300,000 occurence limited to $100,000 per passenger

$500,000 occurence limited to $100,000 per passenger

$1,000,000 occurence limited to $100,000 per passenger

$1,000,000 with no sublimit ("smooth")

Other:

Medical: $1,000 $3,000 $5,000

PILOTS

Pilot 1

Name: Age:

Occupation:

Ratings: Student Private Commercial IFR Multi ATP

Logged Hours: Retractible:

Multi: taildragger:

Hours in plane to be insured:

AOPA Member #

List all pilot's claims, incidents, accidents, FAA medical waivers, FAR violations, DUI & felony convictions.

Pilot 2

Name: Age:

Occupation:

Ratings: Student Private Commercial IFR Multi ATP

Logged Hours: Retractible:

Multi: taildragger:

Hours in plane to be insured:

AOPA Member #

List all pilot's claims, incidents, accidents, FAA medical waivers, FAR violations, DUI & felony convictions.