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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

    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
    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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