Aircraft Insurance Application

Name Of Insured

Address:

Contact Phone: E-mail address:

Business or Occupation

Aircraft Reg. Year, Make&Model: Seats(excl. pilot)

Value On -    Wheels$ Skis$ Floats$ Amphib.$

Aircraft is usually based at  Hangared  Tied Down  Moored

Use of Aircraft:  Pleasure & Business  Rental  Instruction Other Uses

Pilots                                         Pilot 1                          Pilot 2                          Pilot 3

Name                               | |

Age                                  | |

Total Flying Time              | |

Total time last 12 months   | |

Total time on this aircraft    | |

Total Time on floats           | |

Total time on taildragger     | |

Total PIC multi engine time | |

Total retractable time          | |

License Type and number   | |

Endorsements to license      | |

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Accidets/Violations in last 5 years for each pilot- Explain Fully in Comment section below

To list additional pilots carefully use the Comment section below or attach a seperate declaration

Coverages Requested --   Hull    Flight and Ground  Ground Including Taxying  Ground Excluding Taxying

Liability   $1,000,000 BI/PD (Bodily Injury Property Damage Excluding passengers.

                $1,000,000 BI/PD (Bodily Injury Property Damage PLUS $100,000 Passenger Liability(PLL).

                $1,000,000 BI/PD/PLL (no passenger sub limit).

               Other Limits (Specify)

Comments and Additional Information (Something Else? Extra Pilots? - Claims and Violations per pilot?)

I/we declare that the statement and declarations made above are true and that no information has been withheld that might influence any acceptance of insurance; and I / we agree that the statements declarations given above and the application signed by me/us will be the basis of the contract between me/us and the Insurers. I/we further agree that the Insurers may investigate any qualifications or statements contained above, through any source including through any Privacy Act. No coverage is bound under this application form until such time as coverage is confirmed by the Insurers or their authorized representative in writing.

Date:________________________

Applicant's Signature:________________________________

Phone Number:________________ Fax Number:_________________

Broker's Name and Address:_________________________________