Contact Information: 

Name                Occupation/Business      
Individual     INC     LLC     Partnership     Trust     Municipality 

Contact name (if an organization) 

  Address: Street                            City    
                   State                              Zip

          Day Phone      Alternate Phone   

                       Fax                        Email    

Years in Business      

         Airport Base            Airport Code   

Insurance Information: 

Present Ins. Company        Expires MM/DD/YY 

Has applicant had any losses/claims during last 5 years?    No     Yes*  
Has any insurer canceled, declined or refused to renew any aviation insurance?    No     Yes*  
*If yes, please explain: 
 

Liability Limits and Medical Coverages: 

$1,000,000 Combined Single Limit with $100,000 per passenger 
$1,000,000 Combined with no per passenger limitation
Other - Enter amount:  $ 

Medical Coverage Each Passenger:  $3,000 $5,000   $10,000

Additional Coverage: Student Renter Pilot Liability     Non-Owner Liability     Non-Owner Hull  

Coverage $ each aircraft:    

Aircraft Schedule:

Aircraft #1:

FAA#    Make/Mod/Yr   
Value  

Uses (select all that apply): Rental    Instruction    Sightseeing    Charter    Aerial Photo    Sales/Demo

Enter other use(s)  

Aircraft #2:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply): Rental    Instruction     Sightseeing    Charter   Aerial Photo    Sales/Demo 

Enter other use(s)  

Aircraft #3:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply) Rental    Instruction     Sightseeing    Charter   Aerial Photo     Sales/Demo

Enter other use(s)  

Aircraft #4:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply) Rental    Instruction     Sightseeing    Charter   Aerial Photo    Sales/Demo

Enter other use(s)  

Aircraft #5:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply) Rental    Instruction     Sightseeing    Charter   Aerial Photo    Sales/Demo

Enter other use(s)  

Aircraft #6:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply) Rental    Instruction     Sightseeing    Charter   Aerial Photo    Sales/Demo

Enter other use(s)  

Aircraft #7:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply) Rental    Instruction     Sightseeing    Charter   Aerial Photo    Sales/Demo

Enter other use(s)  

Aircraft #8:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply) Rental    Instruction     Sightseeing    Charter   Aerial Photo    Sales/Demo

Enter other use(s)  

Aircraft #9:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply) Rental    Instruction     Sightseeing    Charter   Aerial Photo    Sales/Demo

Enter other use(s)  

Aircraft #10:

FAA#    Make/Mod/Yr   
Value

Uses (select all that apply) Rental    Instruction     Sightseeing    Charter   Aerial Photo    Sales/Demo

Enter other use(s)  

Your current pilot warranty or what you would like to request: 

Fixed Tricycle Gear:   <=200 HP       >201 HP  

Tailwheel Gear:          <=200 HP       >201 HP  

Retractable Gear:       <=200HP       >201 HP  

Multi-Engine:    <=500 Total HP      >501 Total HP  

Rotor Wing:        Gliders:    

Aircraft Losses Past 5 Years: