Contact Information:

First Name

Last Name

Email

Address

Address 2

City

State

Choose OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWADCWVWIWY

Zip

Daytime Phone

Alternate Phone

Fax

Height

Weight

Gender

• Male
• Female

Do You Smoke

• Yes
• No

If YES to smoking please list what kind and frequency of use

Date of Birth

1. Pilot Information:

(1a.) Proposed Insured:

(1b.) In the past 3 years have you been a pilot or received flying instructions?

• Yes
• No

(1c.) Certificate Held:

• Student
• Commercial
• ATP
• IFR
• VFR
• Recreational
• Private

(1d.) Additional Ratings:

• Instrument
• Multi-Engine
• Instructor
• Other (describe in Section 8)

(1e.) Medical Class:

• First
• Second
• Third

(1f.) Date of Last Medical:

(1g.) Date of Last Flight as a Pilot:

(1h.) Type of Aircraft Qualified to Fly:

• Fixed Wing
• Rotary Wing

2. Estimated Flight Hours:

ALL AIRCRAFT

Total Time:

Last 12 Mo.

Est. Next 12 Mo.

GENERAL AVIATION AIRCRAFT

Total Time:

Last 12 Mo.

Est. Next 12 Mo.

 SCHEDULED AIRLINE (135/121)

Total Time:

Last 12 Mo.

Est. Next 12 Mo.

STUDENT

Total Time:

Last 12 Mo.

Est. Next 12 Mo.

MILITARY

Total Time:

Last 12 Mo.

Est. Next 12 Mo.

PLEASURE/RECREATIONAL

Total Time:

Last 12 Mo.

Est. Next 12 Mo.

3.

Have you ever been penalized for a violation of Federal Aviation Regulations?

• Yes
• No

4.

Have you ever had an aviation acciedent or incident?

• Yes
• No

5.

Are you flying under a waiver?

• Yes
• No

6.

List all aircraft that you own, have flown in the past 3 years, or intend to fly:

7.

In the past 3 years have you done:

(7a.) Instruction of Students:

• Yes
• No

(7b.) Aerobatic Flying:

• Yes
• No

(7c.) Ultralight Flying:

• Yes
• No

(7d.) Agricultural Flying:

• Yes
• No

(7e.) Experimental Aircraft:

• Yes
• No

(7f.) Test Flying (For Hire):

• Yes
• No

If yes to question (7f.) please explain here:

8.

Comments:

9.

Desired Coverage:

• Term
• Permanent

Policy Length (Term):

• 10 years
• 15 years
• 20 years
• 30 years

Policy Length (Permanent):

• 10 year
• 15 years
• 20 years
• 25 years
• 30 years

Policy Amount:

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If you used a search engine, which keyword did you look up?

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