For Help Call 412-372-4300 |
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Fields marked (*) are mandatory. |
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Genral Information |
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Registered Owner Name* | |
Address* | |
City* | |
State* | |
Zip* | |
Day Phone* | |
Night Phone | |
Best Time To Call | |
Email Address* | |
Current Aviation Insurance Information |
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Company Name (not agency) | |
Policy Expiration Date | |
Premium Amount ($) | |
Term | |
If Other | |
Aircraft Information |
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Aircraft #1 |
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Year | |
Make/Model | |
Engine Type | |
Horsepower | |
# of seats | |
Date Purchased | |
Purchase Price | |
Present Value | |
Aircraft Cat. |
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Exp | |
Std | |
Aircraft Hangared at | |
Lienholder | |
Additional Insured / Address | |
FAA Reg. # | |
Aircraft #2 |
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Year | |
Make/Model | |
Engine Type | |
Horsepower | |
# of seats | |
Date Purchased | |
Purchase Price | |
Present Value | |
Aircraft Cat. |
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Exp | |
Std | |
Aircraft Hangared at | |
Lienholder | |
Additional Insured / Address | |
FAA Reg. # | |
Aircraft #3 |
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Year | |
Make/Model | |
Engine Type | |
Horsepower | |
# of seats | |
Date Purchased | |
Purchase Price | |
Present Value | |
Aircraft Cat. |
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Exp | |
Std | |
Aircraft Hangared at | |
Lienholder | |
Additional Insured / Address | |
FAA Reg. # | |
Pilots/Operators (always list insured as Pilot #1) |
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Pilot #1 |
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Name | |
DOB | |
Ratings / Certificates | |
Logged Hours |
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Tail Wheel | |
Retract. Gear | |
In Model | |
Last 12 months | |
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions | |
Occupation | |
Pilot #2 |
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Name | |
DOB | |
Ratings / Certificates | |
Logged Hours |
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Tail Wheel | |
Retract. Gear | |
In Model | |
Last 12 months | |
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions | |
Occupation | |
Pilot #3 |
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Name | |
DOB | |
Ratings / Certificates | |
Logged Hours |
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Tail Wheel | |
Retract. Gear | |
In Model | |
Last 12 months | |
Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions | |
Occupation | |
Liability Limit For ALL Air crafts |
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Bodily Injury | |
Property Damage | |
Per seat Medical | |
Hull Coverage For ALL Air crafts |
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Coverage Type | |
Amount Requested ($) | |
Miscellaneous Information |
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Aircraft Use |
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Business & Pleasure | |
Business | |
Pleasure | |
Commercial | |
Passenger Charters | |
Flight Instructor | |
Aircraft Hangared | |
Tied Down | |
Crop Dusting | |
Aircraft Based | |
On Floats | |
Paved Runway | |
Airport Name | |
Airport Location | |
Additional Comments |
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Additional Comments | |