6745 RANGEWOOD DRIVE, SUITE 200
COLORADO SPRINGS, CO 80918

PH: 719-264-9600 FAX: 719-623-1643

Aircraft Insurance Application

APPLICANT

Name of Applicant (Individual, Corporation, LLC):

Phone:

Address:

City:

State:

Zip Code:

Email Address:

Business/Occupation of Applicant:

Requested Policy Term: From:, TO ,

AIRCRAFT

FAA Registration

Aircraft

Seating

N-:

Year, Make, Model:

Crew: Passenger:

N-:

Year, Make, Model:

Crew: Passenger:

Make and Horsepower of Engine(s)

1):

Engine Hours Since New or Last Overhaul:

2):

Engine Hours Since New or Last Overhaul:

If a Standard Airworthiness Certificate is not in full force and effect, please explain:

Annual Utilization – Number of hours aircraft has flown in the last 12 months:

Estimated Next 12 months:

Airport ID aircraft(s) is based at:
Hangared or Tied DownHangaredTied Down

Will the aircraft(s) be operated outside the continental U.S.?:NoYes
If yes, where:

LIABILITY COVERAGE AND LIMITS (If unsure, leave fields blank)

Combined Single Limit Bodily Injury and Property Damage, $ ea, occurrence

Passengers includedexcluded, limited to $ ea. passenger

Medical Payments:$ each person $ ea occurrence

AIRCRAFT PHYSICAL DAMAGE COVERAGE

Hull Value Aircraft 1: Ground & FlightGround Not In Motion

Hull Value Aircraft 2: Ground & FlightGround Not In Motion

OWNERSHIP – APPLICANT

Sole Owner with no liensSole Owner subject to lien with (complete the following below)

Name and Address of Lienholder:

Breach of Warranty Required?:YesNo

LesseeOther

LOSS HISTORY AND PREVIOUS AVIATION INSURANCE

LastPresent Insurance CompanyNoneName of Present Insurance Company

Expiration Date:

Has applicant had any aircraft/aviation losses or claims?:NoYes

Has any insurer ever sent notice of cancellation or refused to renew any aviation insurance for applicant?:NoYes

PILOT INFORMATION

Does any pilot have any medical waivers or limitations other than “Must wear corrective lenses”?

Has any pilot had any claims, incidents, or accidents within the last 5 years?

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?

Please explain all “Yes” answers

Please use this space to provide any additional comments or explanations you would like considered or reviewed

APPLICANT

Name of Applicant:

Title:

Date:

Signature:

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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