Pleasure and Business Aviation Insurance Application

GENERAL INFORMATION

Insured Name:

Current Agent

Mailing Address:

City

State/Region

Zip Code

Cell Number

Business Number:

Residence Number:

Occupation:

Email:*

General Information Membership

Are you an AOPA member?

Yes

AOPA Membership Number:

Membership Number

Effective Date:

Month/Day/Year

Expiration Date:

Month/Day/Year

AIRCRAFT

F.A.A. Reg. No.

Year Built

Aircraft Make & Model

Total Seats (Including Crew)

Agreed Value

Physical Damage Coverage FF/ GNIM/ Liability only/ Ground only

Not in Motion Deductibles

In Motion Deductibles

LIABILITY, COVERAGES, AND LIMITS

Aircraft 1

Combined Liability for Bodily Injury Including Passengers

1. Each Occurrence

1. Each Passenger

Medical Payments (Including Pilot)

2. Each Occurrence

2. Each Passenger

Securement 1

Home Airport Location 1

Aircraft 2

Combined Liability for Bodily Injury Including Passengers

3. Each Occurrence

3. Each Passenger

Medical Payments (Including Pilot)

4. Each Occurrence

4. Each Passenger

Securement 2

Home Airport Location 2

PURPOSE OF USE

There is no coverage in flight if the aircraft is used for any purpose other than the use designated on this document.

P&B: used in business, including personal and pleasure uses, but excluding any operation for hire or profile

IF Other: (Specify)

Pilot 1

Name of Pilot 1

Pilot 1 - Birthdate

Month/Day/Year

Pilot 1 - Total Time

Pilot 1 - TT Retract Gear

Pilot 1 - TT Tail Wheel

Pilot 1 - TT Multi- Engine

Pilot 1 - TT Turbo Prop

Pilot 1 - TT Rotor Wing

Pilot 1 - TT Ski

Pilot 1 - TT Float

Pilot 1 - Total Make & Model in Same Series

Pilot 1 - Total Last 12 Mos.

Pilot 1 - Make & Model Last 12 months

Pilot 1 - Dates of Last MED

Month/Day/Year

Pilot 1 - Dates of Last BFR

Month/Day/Year

Pilot 2

Name of Pilot 2

Pilot 2 - Birthdate

Pilot 2 - Total Time

Pilot 2 - TT Retract Gear

Pilot 2 - TT Tail Wheel

Pilot 2 - TT Multi- Engine

Pilot 2 - TT Turbo Prop

Pilot 2 - TT Rotor Wing

Pilot 2 - TT Ski

Pilot 2 - TT Float

Pilot 2 - Total Make & Model in Same Series

Pilot 2 - Total Last 12 Mos.

Pilot 2 - Make & Model Last 12 Months

Pilot 2 - Dates of Last MED

Month/Day/Year

Pilot 2 - Dates of Last BFR

Month/Day/Year

Pilot 3

Name of Pilot 3

Pilot 3 - Birthdate

Pilot 3 - Total Time

Pilot 3 - TT Retract Gear

Pilot 3 - TT Tail Wheel

Pilot 3 - T Multi- Engine

Pilot 3 - TT Turbo Prop

Pilot 3 - TT Rotor Wing

Pilot 3 - TT Ski

Pilot 3 - TT Float

Pilot 3 - Total Make & Model in Same Series

Pilot 3 - Total Last 12 Mos.

Pilot 3 - Make & Model Last 12 Months

Pilot 3 - Dates of Last MED

Month/Day/Year

Pilot 3 - Dates of Last BFR

Month/Day/Year

Open Pilot Warranty:

OWNERSHIP INFORMATION

Lienholder Name:

Contact:

Owner's Address Complete Address:

1. ADDITIONAL INSURED

1 Additional Insured Name:

1 Additional Insured Complete Address:

1 Certificate of Insurance Required Contact Name:

1 Additional Insured Email:

2. ADDITIONAL INSURED

2. Additional Insured Name:

2. Additional Insured Complete Address:

2. Additional Insured Certificate of Insurance Required Contact Name:

2. Additional Insured Email:

Pleasure and Business Aviation Insurance Application

SECTION 1. APPLICANT SECTION

Name of Last/Current Insurance Company:

Exp. Date

Month/Day/Year

SECTION 2. AIRCRAFT OPERATIONS SECTION (REVIEW & ANSWER CAREFULLY)

A. Does the aircraft have other than a standard airworthiness in full force and effect?

Yes

B. Has the aircraft been equipped with any major modifications not provided by the manufacturer?

Yes

C. Will the aircraft be used for student or pilot instruction other than for training of pilots listed in Pilot Section above?

Yes

D. Will other than the applicant and pilots listed in Pilots Section have use of the aircraft?

Yes

E. Will the aircraft be used for any purpose(s) for which a charge is made?

Yes

F. Is there any unrepaired damage to the aircraft?

Yes

G, Has any applicant had any aircraft or aviation losses/accidents/claims during the last three years?

Yes

H. Has any insurer canceled, declined, or refused to renew any aviation insurance for applicant?

Yes

I. Does any pilot named above have any physical impairments, waivers, or statement of demonstrated ability (other than for corrective lenses)? Limitations or conditions attached to their medical certificate?

Yes

J. Has any pilot named above had any felony convictions, including DUI/DWI or reckless driving, use or possession of drugs, or FAR violation or suspensions or revocations of pilot’s license?

Yes

K. Do you anticipate aircraft to be operated outside of the United States?

Yes

L. Will aircraft be normally operated from other than paved public airports?

Yes

M. Has any pilot named above been involved in any accident or incident within the past 5 years?

Yes

N. Are there any other aircraft owned by the applicant?

Yes

SECTION 3. REMARKS

Please explain any “YES” answer in the space below (referring to SECTION & ITEM above):

Losses - Year, Date, Amount Paid:

(For internal use only) Total Annual Premium:

PLEASE READ AND SIGN

I/ We understand that there is no coverage unless the aircraft is being operated by the pilot(s) designated on this document who has/have at least the certificates, ratings, and pilot experience indicated, and who is/are properly qualified for the flight involved.

I/ We certify that all statements or representations contained on all pages of this application are true and correct and that I/ We have read, understand, and agree with all the particulars contained herein. I/ We agree that the terms and conditions of this application, and the policy currently in use by the insurers, shall be the basis of any contract between me/us and the insurance company. I/ We further agree that the insurance company or their representatives, at their option, but without obligation to do so, may investigate to the extent it deems necessary, any qualification or statement contained in this application, not properly described herein has any unrepaired damage as of the effective date of this application, and that I/ We are the sole and unconditional owners of the property. I/ We authorize Falcon Insurance Agency, Inc. to represent me/us in placing this insurance.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto a fraudulent act, which is a crime.

Applicant Signature:

Date

Month/Day/Year

Are you an AOPA member