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Helicopter Single Ship Standard Uses Insurance Quote Request

This form is used for a Helicopter insurance quotation.  It can be used for both pleasure & business (non-commercial) quotations and commercial use quotations such as: Rental and Flight Instruction, Part 135 Charter Operations, Part 91 Sightseeing For Hire, Aerial Photography, External Loads to name a few. Please complete this form to receive your insurance quote.

  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 


Co-owner Information:

Name       Occupation/Business    
Individual     INC      LLC      Partnership     Trust


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 Insurance Coverage Limit: 
 $1,000,000 Combined Single Limit with $100,000 per passenger 
 $1,000,000 Combined Single Limit with $200,000 per passenger  
 $1,000,000 Combined Single Limit*  
 $ Combined Single Limit*  
          *There is no per-passenger sub limit

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


Helicopter Information:

FAA #:     Year:      Make: 

Model:       Insured Value:

Airport/Heliport Base:   Airport/Heliport ID:    Hangared

Aircraft Use: 
 Pleasure & Business Only (no commercial operations where a charge is made)  
  Rental & Instruction    Instruction Only    Part 91 Sightseeing    Aerial Photo  
  Part 135 Charter      External Load     Other: 


Pilot Information:

Pilot #1:

Name:          Age: 

Type of License:   Student    Private    Commercial    ATP

Ratings:   Rotorwing    Instrument     SEL      MEL    CFI      CFII    Other:

Total Flight Time:        Total Rotorwing Hours:

Hours in Insured Model:  

Piston Rotorwing Hours:      Turbine Rotorwing Hours:

Name and Date of completion of the last Formal, Initial, or Recurrent Training School for this make & model. 
Name of School:      Date of Completion: 

Pilot listed above has a valid and effective pilot certificate and has had no aviation accidents, incidents or certificate suspensions, DUI or DWI's unless noted here: 
  


Pilot #2:

Name:          Age: 

Type of License:   Student    Private    Commercial    ATP

Ratings:   Rotorwing    Instrument     SEL      MEL    CFI      CFII    Other:

Total Flight Time:        Total Rotorwing Hours:

Hours in Insured Model:  

Piston Rotorwing Hours:      Turbine Rotorwing Hours:

Name and Date of completion of the last Formal, Initial, or Recurrent Training School for this make & model. 
Name of School:      Date of Completion: 

Pilot listed above has a valid and effective pilot certificate and has had no aviation accidents, incidents or certificate suspensions, DUI or DWI's unless noted here: 
  


Pilot #3:

Name:          Age: 

Type of License:   Student    Private    Commercial    ATP

Ratings:   Rotorwing    Instrument     SEL      MEL    CFI      CFII    Other:

Total Flight Time:        Total Rotorwing Hours:

Hours in Insured Model:  

Piston Rotorwing Hours:      Turbine Rotorwing Hours:

Name and Date of completion of the last Formal, Initial, or Recurrent Training School for this make & model. 
Name of School:      Date of Completion: 

Pilot listed above has a valid and effective pilot certificate and has had no aviation accidents, incidents or certificate suspensions, DUI or DWI's unless noted here: 
  


Pilot #4:

Name:          Age: 

Type of License:   Student    Private    Commercial    ATP

Ratings:   Rotorwing    Instrument     SEL      MEL    CFI      CFII    Other:

Total Flight Time:        Total Rotorwing Hours:

Hours in Insured Model:  

Piston Rotorwing Hours:      Turbine Rotorwing Hours:

Name and Date of completion of the last Formal, Initial, or Recurrent Training School for this make & model. 
Name of School:      Date of Completion: 

Pilot listed above has a valid and effective pilot certificate and has had no aviation accidents, incidents or certificate suspensions, DUI or DWI's unless noted here: 
  

Anything else that we need to know: