Call: 719-264-9600

    APPLICANT

    , TO ,

    AIRCRAFT

    FAA Registration

    Aircraft

    Seating

    NoYes

    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

    StudentPrivateCommercialATPInstrument RatingCFICFIIAMELASELASESAMES

    Pilot 2

    Applicable licenses or ratings

    StudentPrivateCommercialATPInstrument RatingCFICFIIAMELASELASESAMES

    Pilot 3

    Applicable licenses or ratings

    StudentPrivateCommercialATPInstrument RatingCFICFIIAMELASELASESAMES

    Pilot 4

    Applicable licenses or ratings

    StudentPrivateCommercialATPInstrument RatingCFICFIIAMELASELASESAMES

    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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