Aircraft

	AviationUnderwriters.com

Aircraft insurance application-To be used for all types of aircraft including helicopters

Ownership/Applicant/Contact information
Name of applicant:
Registered owner of the aircraft if different:
Business/Occupation of applicant/owner
Is there more than one owner of the aircraft? (if more than one owner, we will collect the information on the other owners after we quote. This may affect the rate charged)
Address-Street, City, State/Province, Country, Postal/Zip Code ►►►► PLEASE provide your complete address
your eMail address
alternate eMail
Telephone-Business
Telephone-Home
Telephone-other
Telecopier/fax number
Expiration of current insurance
Name of current insurer
Present annual premium (USD) Currency converter
Aircraft information
Is there more than one aircraft to be insured at this time?
If more than one aircraft to be insured at this time please complete information below for flagship airplane and indicate how many others are to be covered. We will contact you to obtain details for the other units. Enter total number of aircraft units to be insured including the unit listed below: Units to be insured.
Aircraft year of construction
Aircraft make
Aircraft model
Aircraft type
Number of engines
Type of engines (piston, turbine, etc.)
Total horsepower of all engines
Engine hours since New or SMOH	Engine 1 Engine 2 Engine 3 Engine 4
Hours aircraft flown last twelve months
Aircraft registration/tail number
Number of crew seats
Number of passenger seats
Aircraft based (Identifier and field name)
Runway surface
Is this a licensed airfield?
Is the aircraft normally kept in a hanger? If so, state construction.	Not hangared
Describe all unrepaired damage to your aircraft	No unrepaired damage to airplane
Will you make any charge, receive any money or any other compensation or reward for use of your aircraft other than sharing the cost of fuel, oil, landing fees, customs fees or temporary parking for a flight with your
passengers?
READ CAREFULLY: State purposes for which aircraft will be used. Check all that apply.
1. Pleasure & Business means personal and pleasure use and use in direct connection with the Insured's business, excluding any operation for which a charge is made.
2. Industrial Aid includes 1.) above and also includes transportation of executives, employees, guests and customers, excluding any operation for which a charge is made.
3. Limited Commercial includes 1.) & 2.) above plus Student Instruction and Short Term Rental to pilots but excluding transportation of passengers &/or freight for hire or reward.
4. Commercial ex-instruction or Rental includes 1.), 2.) & 3) above EXCLUDING Student Instruction and Short Term Rental to pilots, EXCLUDING crop dusting, spraying, seeding or any form of hunting, pest or varmint control but INCLUDING all other operations in the business of the Applicant.
5. Commercial includes all operations in the business of the Applicant EXCLUDING Student Instruction, EXCLUDING crop dusting, spraying, seeding or any form of hunting, pest or varmint control but INCLUDING Short Term Rental to pilots.
6. Commercial including instruction includes all operations in the business of the Applicant INCLUDING Student Instruction and Short Term Rental to pilots, EXCLUDING crop dusting, spraying, seeding or any form of hunting, pest or varmint control. *If instruction is included do you instruct Low Time (less than 100 hours or Beginner) pilots?*
7. Flying Club includes 1.) above ONLY. NO rental, NO charter If so specify: the number of Student pilots: Private pilots: Commercial pilots:
8. Special Uses: (Specify)No special uses
Will the aircraft be flown at night in during the next 12 months?
Will the aircraft be flown in IFR conditions during the next 12 months?
Geographical (navigational) limits for aircraft
Do you fly in French Airspace? There is a surcharge for French airspace navigation
Who maintains the aircraft?
Lienholder requires breach of warranty coverage?		Amount of lien
Name and address of lienholder
Pilot information
Pilot 1 name
Pilot 1 date of birth
Pilot 1 certificates and ratings
Pilot 1 total hours logged all aircraft
Pilot 1 total hours logged last 90 days
Pilot 1 total hours logged retractable aircraft
Pilot 1 total hours logged multi-engine aircraft
Pilot 1 total hours logged this aircraft or M&M
Date of last physical examination (Month and year only)
Date of last BFR/Checkride(Month and year only)
Do you have any Physical Impairments?

Do you have any waivers, limitations, conditions, restrictions or similar endorsements attached to your Medical Certificate?

Has any Pilot Certificate held by you ever been suspended, cancelled or revoked?

Have you ever been cited for any violation of any government Air regulations or similar ordinance?
Have you ever been involved in any aircraft accident or incident (reported or not)?

Have you ever been convicted of or pleaded guilty, or equivalent to a felony/criminal act or for drunken driving or operating a vehicle or aircraft under the influence of drugs?

List ALL aviation insurance claims and/or prior aviation loss history insured or not insured in the last 10 years. Attach as separate page in insufficient space to explain and eMail to jpc@alliedbvi.com or fax to 661-420-8602. If no losses past 10 years, insured or not insured write "NONE"
No additional pilots-Go to next section

Pilot 2 name
Pilot 2 date of birth
Pilot 2 certificates and ratings
Pilot 2 total hours logged all aircraft
Pilot 2 total hours logged last 90 days
Pilot 2 total hours logged retractable aircraft
Pilot 2 total hours logged multi-engine aircraft
Pilot 2 total hours logged this aircraft or M&M
No additional pilots-Go to next section

Pilot 3 name
Pilot 3 date of birth
Pilot 3 certificates and ratings
Pilot 3 total hours all aircraft
Pilot 3 total hours logged last 90 days
Pilot 3 total hours logged multi-engine aircraft
Pilot 3 total hours logged retractable aircraft
Pilot 3 total logged hours this aircraft or M&M
No additional pilots-Go to next section

Pilot 4 name
Pilot 4 date of birth
Pilot 4 certificates and ratings
Pilot 4 total hours all aircraft
Pilot 4 total hours logged last 90 days
Pilot 4 total hours logged multi-engine aircraft
Pilot 4 total hours logged retractable aircraft
Pilot 4 total logged hours this aircraft or M&M

Coverage required
Aircraft insurance (Hull) value (USD please) ► Currency converter
Physical Damage to your aircraft to be covered:
Liability limit requested (USD please) Currency converter Suggested limits shown. You may request different amounts	each occurrence (USD)		◄Suggested limits shown. ◄You may request different limits/amounts
	each passenger (USD)

List names of all Additional Insureds:
Remarks: Please enter any information or comments that may be useful to Underwriters

Important note: Please review entire submission carefully before submitting this form as false information may void your insurance. Submitting this form does not bind you to purchase the insurance or any Insurer to accept the risk, however it is agreed that the information submitted shall be the basis of the quotation and contract should coverage be bound and/or a policy issued. No coverage is bound or in force until confirmed in writing by our office. The information collected from you is used to underwrite coverage and services. This information will be provided to others. I have read the Important Information and understand and agree with the contents thereof.