Aircraft Insurance by AV FundSource

Please complete the form below and we will respond with your quote a quickly as possible. Also, please be sure to include your contact information so we can either call or email your quote. Thank You.

APPLICANT INFORMATION

First Name

Last Name

Address

City

State Zip

Work # Home #

Fax # Email

Occupation

Present Insurance Carrier /Indicate If New Or Prospective Purchase

Insurance Expiration Date

Are You A Member of AOPA Yes No
If Yes, AOPA Member Number

Are You A Member Of EAA Yes No
If Yes, EAA Member Number

Has the applicant had any aviation related losses/incidents (claims) in the past 5 years? Yes No

If yes was answered to the question above, please give details to include dates, type of loss/incident, amount paid, etc.

AIRCRAFT INFORMATION

FAA - N # Make

Model Year

Seats ( including pilot )

Insured Value

Base Airport Location

Base Airport ID

Aircraft Is

Aircraft Use(s)

Lien Holder Name

Lien Amount

Coverages Requested---Liability Limits

$500,000 Combined Single Limit-Passengers Limited to $100,000

$1,000,000 Combined Single Limit-Passengers limited to $100,000

$1,000,000 Combined Single Limit-No Separate Passenger Sub-Limits

Other(Specify)

Medical Coverage Each Passenger

PILOT #1 INFORMATION

Pilot #1 Full Name

Date of Birth

Current Employer

Date of last Biennial Flight Review

Airman's Certificate Number

Have You Attended Any Formal Ground & Flight Or Simulator Training For The Requested Make & Model Aircraft ? YES NO

IF Yes, Please Indicate Specifics Of Training, Where Attended, and Date Last Completed.

Check Any of the Following Certification and Ratings That Apply

Student Private Commercial

Airline Transport(ATP) Instructor(CFI)

Instrument Instructor(CFII) Rotorwing Instructor

Multi Engine Instructor(MEI) Instrument Rating

Single Engine Land Multi Engine Land

Seaplane Multi Engine Sea Rotorwing

Center Line Thrust Glider

Mechanic, Aircraft and Power Plant

Type Ratings & Endorsements(Specify)

Pilot #1 Aircraft Hours

Total Logged Hours Multi Engine Hours

Single Engine Retract Hours Tailwheel Hours

Turbo Prop Hours Turbo Jet Hours

Rotorwing Hours Seaplane/Amphibian Hours

Total Logged Hours In Make & Model

Total Logged Hours In Make & Model Last 90 Days

Total Logged Hours In Make & Model Last 12 Months

Total Logged Hours In All Aircraft Last 90 Days

Total Logged Hours In All Aircraft Last 12 Months

PLEASE EXPLAIN ANY YES ANSWERS TO THE FOLLOWING QUESTIONS IN THE SPACE PROVIDED BELOW.

1. Do you have any physical condition(s), limitation(s) or impairment(s) that require a waiver or special condition to be attached or indicated on your Medical Certificate? YES NO

2. Has your FAA or DOT or Military Pilot Certificate ever been suspended or revoked? YES NO

3. Have you ever been cited for any violations of Federal or Canadian Air Regulations or have limitations ever been placed on your Pilot Certificate? YES NO

4. Arising out of the operation of a Motor Vehicle, have you had your driver's license suspended or revoked during the past 5 years? YES NO

5. Have you been convicted or pleaded guilty to a charge of reckless driving or driving under the influence of alcohol or drugs during the past 5 years? YES NO

6. Have you ever had an application for Aircraft Hull or Liability insurance declined by an insurance company? (Question #6 not applicable in states where prohibited by law ) YES NO

7. Have you ever had any aircraft accidents or incidents while acting as Pilot within the past five years? [If "Yes", give dates, places, make and model of aircraft and details of Accidents/Incidents]
YES NO

Explanations Below

PILOT #2 INFORMATION (only required if there is to be more than one named pilot)

Pilot #2 Full Name