| Owner's Name: |
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| Address: |
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| City: |
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| State/Province: |
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| Postal Code: |
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| Occupation: |
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| Day Phone: |
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| Your E-mail Address: |
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|
5% discount through AIG for AOPA members.
Enter your AOPA member number: |
|
|
| Present Insurance |
| Company: |
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| Expiration Date: |
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| Aircraft |
| Make/Model: |
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| FAA#: |
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| Land/Sea/Amphibious: |
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| Year/Model: |
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| Total Seats: |
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| Insured Value: $ |
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| Aircraft Based |
| Airport: |
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| City: |
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| State/Province: |
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| Airport I.D.: |
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| Hangared or Tied?: |
Hangared
Tied |
| Aircraft Use: |
Pleasure & Business
Industrial Aid
Other: |
| Lien Holder: |
|
| Amount: |
$ |
| Limits of Liability: |
500,000/Occurence limited to 100,000/Passenger
1,000,000/Occurence limited to 100,000/Passenger
1,000,000/Occurence limited to no Passenger Limitation
Other:
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| Medical Payments: |
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| Pilot Status |
| Pilot 1 |
| Name: |
|
| Occupation: |
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| Date of Birth: |
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| Ratings (check all that apply): |
Student
Private
Commercial
Instrument
Multi-Engine
ATP |
| Logged Hours |
|
|
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| Pilot 2 |
| Name: |
|
| Occupation: |
|
| Date of Birth: |
|
| Ratings (check all that apply): |
Student
Private
Commercial
Instrument
Multi-Engine
ATP
|
| Logged Hours |
|
|
|
| Pilot 3 |
| Name: |
|
| Occupation: |
|
| Date of Birth: |
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| Ratings (check all that apply): |
Student
Private
Commercial
Instrument
Multi-Engine
ATP
|
| Logged Hours |
|
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| Annual Proficiency Training? |
No
Yes
Date:
Type:
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| |
