Aircraft Insurance Application Form

Name: *

Address:

City:

Province:

Postal Code:

Telephone:

Email:

Fax:

Occupation of Insured:

Current Insurer:

Date of Expiry:

Expiring Premium:

Aircraft Year, Make & Model:

Aircraft Registration Number:

Seating Available:

Wheels:

Skis:

Yes

No

Floats:

Yes

No

Amphibian:

Yes

No

Hull - At Risk Flight & Ground:

All Risk Ground Excluding Taxying:

Liability:

$1,000,000 BI/PD Excluding Passengers

$1,000,000 BI/PD No Passenger Sub-Limints

Other

If Other Please Specify:

Aircraft Base:

Location, City, Town ... etc.

Aircraft Storage:

Aircraft Use:

If Other Please Specify:

Full name and Date of Birth:

Pilot information

License Number & Type:

Endorsement to License:

Total Flight Time:

Total Flight Time in past 12 Months:

Total Time of Aircraft Stated Above:

Total Time on Floats:

Leave blank if it does not apply

Total Time Taildragger:

Leave blank if it does not apply

Total Time Multi Engine PIC Time:

Leave blank if it does not apply.

Total Time Retractable:

Leave blank if it does not apply.

Accidents or Violations:

Leave blank if it does not apply.

Accidents or Violations within the past 5 years:

Leave blank if it does not apply.