Report a Claim Form
(Required Information is in Bold Italics Type)
 

 

Today's Date (MM/DD/YY):                                         Agent:
                           

Policy#:                                               Policy Effective Date:                          Policy Type:        
          Aircraft   AGL 


Insured:    

Contact (if different): 

Street Address: 

City/State/Zip: 

Cell Phone: 

Other phone: 

Email/Fax: 

 

Date Of Loss (MM/DD/YY):   

Location of Loss/Aircraft: 


Coverages    

      Limits   
For Aircraft Coverages:  
                                                         Each Occurrence                                 Each Passenger
Combined Single Limit Liability:  $     $
Medical Payments: $ Each Passenger
Hull Coverage: $ 
Deductibles:   $ not in motion,          $ in motion
For Airport Coverages:  
Airport General Liability Limit: $ Each Occurrence
Products Liability Limit: $ Each Occurrence
Hangarkeepers Liability Limit: $ Each Aircraft
Deductible:  $  $ Each Occurrence

*Description of Loss: 

Third Party Bodily Injury or Property Damage: 

Estimate of Damage: