URLThis field is for validation purposes and should be left unchanged.Personal InformationFull Name:(Required) First Last Date Of Birth:(Required) MM slash DD slash YYYY Gender:(Required) Male Female Marital Status:(Required) Single Married Divorced Widowed Spouse Full Name:(Required) First Last Spouse Date Of Birth:(Required) MM slash DD slash YYYY Spouse Gender:(Required) Male Female Home Address:(Required) Street Address City State / Province / Region ZIP / Postal Code Phone Number:(Required)Email Address:(Required) Pilot QualificationsName Of Pilot:(Required) Full Name FAA Certificate #:(Required)Pilot Certificate Type:(Required) Student Private Commercial ATP Other Certificate Number:(Required)Date Issued:(Required) MM slash DD slash YYYY Ratings Held:(Required) Single-Engine Land Multi-Engine Instrument Other Total Flight Hours:(Required)Total Hours in Last 12 Months:(Required)Total Hours in Aircraft Type Typically Rented/Borrowed:(Required)Medical Certificate Class:(Required) 1st 2nd 3rd BasicMed Date of Last Flight Review (BFR):(Required) MM slash DD slash YYYY Any FAA violations or suspensions?(Required) Yes No If yes, provide explanation:(Required)Details of other proficiency training:For Flight InstructorsDo you Hold a Master CFI Designation?(Required) Yes No Type of Aircraft?(Required)Rented or Borrowed?(Required)What Is the Greatest Seating Capacity of Aircraft?(Required)Average Seating Capacity?(Required)Aircraft Base Location:(Required) City State / Province / Region Are Any Flights Contemplated Outside Continental U.S?(Required) Yes No If "Yes" where?(Required)Requested Coverage (Please provide total aggregate limits for each) Non Owned Bodily Injury:(Required)Property Damage:(Required)Physical damage Liability to Non-Owned Aircraft:(Required)Preferred Deductiable:(Required)Do you require legal defense coverage?(Required) Yes No If yes, please describe limits:(Required)Do you require coverage for the following:(Required)(Check all that apply below) Passengers Baggage and personal effects Non-owned hull physical damage (if available) Non-owned hangar and ground equipment liability Usage and Operation:(Required) Pleasure Business Fly on Behalf of Employer Limited Commercial Instruction of: (Name of Student) Special Uses (Other): Instruction of:(Required)Describe special uses:(Required)Supplemental QuestionsDoes the aircraft to be rented have OTHER than a standard airworthiness certificate in full effect?(Required) Yes No If yes, please explain:(Required)Are there any other aircraft owned by the applicant?(Required) Yes No If yes, please describe other aircraft owned:(Required)Has the aircraft been equipped with modifications?(Required) Yes No If yes, please describe modifications:(Required)Will the aircraft be operated in OTHER than paved public airports?(Required) Yes No If yes, please explain other operations:(Required)Will the aircraft be used for student or pilot instruction OTHER than the recurrent training of pilots listed in the "Pilot Information" section of this application?(Required) Yes No If yes, please explain instruction uses:(Required)Has the applicant listed in the "Pilot Information" section of this application ever been in an aircraft accident?(Required) Yes No If yes, please explain accident(s):(Required)Has the applicant listed in the "Pilot Information" section of this application ever been cited for violation of any aviation regulation in any country?(Required) Yes No If yes, please explain citation(s):(Required)Has the applicant listed in the "Pilot Information" section of this application ever had an FAA, Military, or other pilot certificate suspended or revoked?(Required) Yes No If yes, please explain suspension(s) or revocation(s):(Required)Does the applicant listed in "Pilot Information" section of the application have any; (a) physical impairments, (b) waivers, limitation, conditions on their medical certificate or on their airman certificates?(Required) Yes No If yes, please describe circumstances:(Required)Has the applicant ever been convicted of or plead guilty to a felony, possession of drugs, or of driving while intoxicated?(Required) Yes No If yes, please explain:(Required)Aircraft Use InformationDo you currently own or lease any aircraft?(Required) Yes No How frequently do you rent or borrow aircraft?(Required)(e.g, weekly, monthly, ocasionally)Purpose of use:(Required) Personal Use Business Instruction Other Typical aircraft make/model flown:(Required)Estimated annual flight hours in rented/borrowed aircraft:(Required)Coverage NeedsRequested Liability Limit:(Required)Insurance HistoryHave you previously held non-owner aviation insurance?(Required) Yes No If yes, provide carrier name and policy term:(Required)Any aviation-related claims or losses in the past 5 years?(Required) Yes No If yes, describe incident(s):(Required)Current Insurance Carrier (if any)Additional InformationUse the space below to provide any other relevant information or special considerations that may affect your insurance policy. 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