Aviation Insurance Application
Named Insured *
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Address
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City
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State
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Zip Code
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Phone
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Email
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AOPA Member
AOPA Member Number
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Current Insurance Company & Expiration Date
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Coverage / Limits Requested
Liability
Custom CSL
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Custom Per Passenger Limit
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Hull Coverage
Medical Payments each Passenger including Crew
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Aircraft Information
Aircraft 1 Year - Make - Model
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Airport where based
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Hangared or Tied Down
Aircraft 1 - Number of Seats Crew / Passenger
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Aircraft 1 - FAA N#
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Aircraft 1 - Engine Hours SMOH
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Aircraft 1 - Engine HP
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Aircraft 1 - Engine Manufacturer
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Aircraft 1 - Aircraft Purchase Amount
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Aircraft 1 - Date Purchased
MM
/
DD
/
YYYY
Aircraft 1 Insured Value
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Pilot Information
Pilot 1 Name
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Pilot 1 DOB
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Pilot 1 Certificates
Pilot 1 Ratings
Pilot 1 Medical Expiration Date
MM
/
DD
/
YYYY
Pilot 1 Date of Last Flight Review
MM
/
DD
/
YYYY
Pilot 1 Total Hours
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Pilot 1 Hours Flown in this Make and Model
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Pilot 1 Hours Flown in the Last 12 Months
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Pilot 1 Retractable Gear Total Hours
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Pilot 1 Multi Engine Total Hours
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Pilot 1 Details of Any Losses/Waivers/Violations?
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