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6745 RANGEWOOD DRIVE, SUITE 200
COLORADO SPRINGS, CO 80918
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PH: 719-264-9600 FAX: 719-623-1643

Aircraft Insurance Application

APPLICANT
, TO ,
AIRCRAFT
FAA Registration
Aircraft
Seating
Make and Horsepower of Engine(s)

HangaredTied Down
NoYes
Use of Aircraft
Pleasure and BusinessPatrol FlightsBanner TowingPhotographyCharter(Part 135)OtherCorporate(Industrial Aid) – Flown by professional pilots employed for this purpose
Other Uses (Explain)
LIABILITY COVERAGE AND LIMITS (If unsure, leave fields blank)
ea, occurrence
includedexcluded, limited to $ ea. passenger
  ea occurrence
AIRCRAFT PHYSICAL DAMAGE COVERAGE
    Ground & FlightGround Not In Motion
    Ground & FlightGround Not In Motion
OWNERSHIP – APPLICANT
Sole Owner with no liensSole Owner subject to lien with (complete the following below)
YesNo
LesseeOther
LOSS HISTORY AND PREVIOUS AVIATION INSURANCE
LastPresent Insurance CompanyNone
NoYes
NoYes
PILOT INFORMATION
Pilot 1
Applicable licenses or ratings

StudentPrivateCommercialATPCFICFIIAMELASELASESAMES
Pilot 2
Applicable licenses or ratings

StudentPrivateCommercialATPCFICFIIAMELASELASESAMES
Pilot 3
Applicable licenses or ratings

StudentPrivateCommercialATPCFICFIIAMELASELASESAMES
Pilot 4
Applicable licenses or ratings

StudentPrivateCommercialATPCFICFIIAMELASELASESAMES
Does any pilot have any convictions, suspensions, or revocations relating to driver’s license or airman’s certificate for FAR violations, use, or possession of controlled substance, or driving while intoxicated?
APPLICANT





By signing this application, I hereby agree that all information submitted is true and accurate to the best of my knowledge and no information has been withheld or suppressed.



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