Please complete this application thoroughly...

Owner Info
Name:
AOPA Number:
Home Phone#:
Cell Phone#:
Fax #: 
E-mail Address:

Street Address:
City:
State: Zip:
Occupation: 
Current Ins. Co.:
  Policy Renewal Date:

Aircraft
Aircraft Make/Model:
Year of Manuf.:  N#:
Value Desired:$
Airport Identifier (KABC):  is Paved or Turf.
Longest Runway:  ft. -Aircraft isHangared or Tied
Aircraft Used For (select options as necessary) :
Pleasure & Business (not for-hire) Corporate (hired pilots only)
Aerial Photo  Banner Towing
Patrol Flights  Flying Club 
Crop Dusting Instruction & Rental 
Passenger Carrying for Hire Cargo for Hire

Other uses not listed: 
Has the aircraft been modified by any conversions?Yes No
Liability coverage desired :

 

Will aircraft be mortgaged by bank or private party?Yes No
Pilots

Pilot 1: 

Age:

Total Hours:

Multi-eng. Hours.: 

Retract-gear Hours:

Tail wheel Hours:
Turboprop Hours
Turbojet Hours:
Total Hours flown in last 90 days:
Total Hours flown in past 12 Months:

Hours in type aircraft to be quoted:

Ratings: 

Certificates:  

 IFR   Multi-engine

Pilot 2: 

Age:

Total Hours:

Multi-eng. Hrs.: 

Retract-gear Hours:

Tail wheel Hours:
Turboprop Hours:
Turbojet Hours:
Total Hours flown in last 90 days
Total Hours flown in past 12 Months:

Hours in type aircraft to be quoted:

Ratings: 

Certificates:  

 IFR  Multi-engine

Pilot 3: 

Age:

Total Hours:

Multi-eng. Hrs.: 

Retract-gear Hours:

Tail wheel Hours:
Turboprop Hours:
Turbojet Hours:
Total Hours flown in last 90 days
Total Hours flown in past 12 Months:
Hours in type aircraft to be quoted:

Ratings: 

Certificates:  

 IFR   Multi-engine

Pilot 4: 

Age:

Total Hours:

Multi-eng. Hrs.: 

Retract-gear Hours:

Tail wheel Hours:
Turboprop Hours:
Turbojet Hours:
Total Hours flown in last 90 days
Total Hours flown in past 12 Months:
Hours in type aircraft to be quoted:

Ratings: 

Certificates:  

 IFR   Multi-engine

List information on all prior aviation claims, accidents, losses, DUI/DWI's, felonies, FAA Suspension, revocation or violation actions, or medical waivers: 

 
PLEASE NOTE: By requesting a insurance proposal from Aviation Insurance Brokers of North America using this form; you are warranting that the information submitted is true and correct to the best of your knowledge, and that no information has been withheld or suppressed. Coverage cannot be activated unless a written Binder is first issued by Aviation Insurance Brokers of North America, as confirmation of insurance.