Insurance Aviation Application

AVIATION INSURANCE APPLICATION

Applicant / Insured Information

Applicant Name:

Individual Corporation LLC Partnership Other

Contact Phone:    Email:

Date of Birth (if individual):    Tax ID / SSN:

Policy Details Requested

Policy Type Requested: Hull (Physical Damage) Liability Combined Hull & Liability Passenger Accident

Policy Period: From to

Aircraft Information (Primary)

Year of Manufacture:    Serial Number:    Registration Mark:

Operations & Use

Base Airport:

Intended Use: Private Commercial Charter Flight Instruction Cargo Aerial Application

Average Hours Per Year:

Pilot Information

Certifications: IFR ATP Commercial Private

Total Flight Hours:    Hours in Type:    Flight Review / Currency Date:

Any FAA or equivalent regulatory actions, revocations, suspensions, accidents, or claims in last 5 years? Yes No

Loss / Claims History (Last 5 Years)

Coverage Options & Endorsements

Hull — Physical Damage Coverage

Ground Risk Including Taxiing (excluding passenger loading/unloading unless specified)

Passenger Liability Coverage

Passenger Accident Limit:

Delete War and Terrorism Exclusion

Spare Parts Coverage

Exclusions, Representations & Warranties

The applicant represents that the information provided in this application is true, complete and correctly sets forth all material facts. It is understood that any misrepresentation, omission or concealment of a material fact may render any coverage voidable or permit the insurer to rescind coverage to the extent permitted by law. Coverage is subject to the terms, conditions, limits and exclusions of the policy issued.

The insurer is authorized to obtain and verify claim history, pilot records, maintenance records and underwriting information from any source including prior insurers, regulatory authorities and service facilities. The applicant shall provide copies of maintenance logs and pilot records upon request.

Fraud Warning: Any person who knowingly submits false or fraudulent information in connection with an insurance application or claim may be subject to criminal and civil penalties under applicable law.

I certify that the information supplied in this application is true and complete to the best of my knowledge and that no material facts have been withheld.

Beneficiary Designation (Passenger Accident or Personal Accident Benefit)

Beneficiary Name:

Relationship:    Percentage: %

Authorization & Declaration

By signing below, the applicant authorizes the insurer and its representatives to obtain and disclose underwriting and claim information relevant to this application. The applicant acknowledges that coverage, if issued, will be based upon the representations contained herein and any supplemental documentation submitted. The applicant agrees to notify the insurer of any material change in operations, ownership, or pilot qualifications before the effective date of the policy or during the policy period.

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