| Present
Insurance Company
(not agent) |
|
| Policy
Expirattion Date |
|
Please
enter date as: mm/dd/yyyy
Example using today's date: 02/09/2012 |
|
Is there a Co-Owner?
If so give complete Name |
|
| Please
provide a brief
descripton of your operations |
|
| |
| Coverages |
|
Liability
Limits |
$500,000 Combined Single Limit
with $100,000 per passenger |
|
|
$1,000,000 Combined Single Limit
with $100,000 per passenger |
|
|
$1,000,000 Combined with no per
passenger limitation |
|
|
$
Combined Single limit with no passenger limitation |
|
|
Medical Coverage
Each Passenger
|
$1,000
$3,000
$5,000
|
|
Use:
|
Pleasure and Business
Commercial, Charter for Hire
|
|
|
Aircraft is based at
|
and
is
Hangered or
Tied down |
| |
|
Pilot
Information |
|
|
|
Pilot
One |
Pilot
Two |
Pilot
Three |
|
Name |
|
|
|
|
Age |
|
|
|
|
License |
|
|
|
|
Ratings |
|
|
|
|
Total Flight Time |
|
|
|
|
Hours in Model |
|
|
|
|
Hours in Retractable |
|
|
|
|
Hours in Multi-Engine |
|
|
|
|
Hours in Tailwheel |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
