AIRCRAFT INSURANCE: INSURED NAME ADDRESS PHONE EMAIL POLICY EXPIRATION / CLOSING DATE AIRCRAFT YEAR, MAKE, AND MODEL INSURED/MARKET VALUE FAA N# # OF SEATS AIRPORT BASE HANGARED OR TIED LIMIT OF LIABILITY REQUESTED WILL THE AIRCRAFT BE OPERATED FROM UNPAVED RUNWAYS DOES THE AIRCRAFT HAVE AN IFR GPS WITH MOVING MAP AND 2 AXIS AUTOPILOT AOPA # EAA # PILOT NAME PILOT DOB FAA LICENSE & TYPE RATINGS TOTAL HOURS TOTAL HOURS IN INSURED AIRCRAFT TOTAL HOURS PAST 12 MONTHS TOTAL HOURS PAST 12 MONTHS IN INSURED AIRCRAFT DATE AND TYPE OF LAST TRAINING ANY ACCIDENTS, INCIDENTS, DUIs, CONVICTIONS, LIMITATIONS MULTI ENGINE TIME RETRACTABLE GEAR TIME ALL OF THE INFORMATION HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND I HAVE NOT KNOWINGLY OR INTENTIONALLY CONCEALED OR MISREPRESENTED ANY FACT. THIS FORM WILL BECOME PART OF THE INSURANCE APPLICATION AND AS SUCH ALL FRAUD STATEMENTS ARE APPLICABLE.
