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Rental Pilot Application
Application for Rental Pilots | Non Owned Aircraft Liability for Individuals Only
Named Insured:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Email Address
*
Fax
Occupation:
Date of Birth:
-
Month
-
Day
Year
Total Logged Hours:
Last 12 Months:
License/Permit:
Student
Rec
Ultra-light
Ultra-Light with Passenger Carrying
Pvt
Comm
ATP
Helicopter
Your Ratings:
Instructor
Other
Will you be using an aircraft for more than 30 consecutive days?
Yes
No
What type of aircraft do you typically fly:
PIC Time on Type:
Is the aircraft:
Floats
Multi Engine
Rotary
Aircraft Use:
Private Business & Pleasure
Commercial
Instruction
Have you had any accidents/incidents/claims or violations in the past 3 Years:
Coverage Details – Please choose liability limit from either Option A or Option B but not both:
Option A:
Desired Third Party Bodily Injury/Property Damage Liability Limit:
$100,000
$500,000
$1,000,000
$2,000,000
$3,000,000
Desired Passenger Liability Limit to supplement Third Party:
$0
$100,000
$300,000
Option B:
Desired Combined Single Liability Limit Bodily Injury & Property Damage, Including Passengers:
$1,000,000
$2,000,000
$3,000,000
What is the maximum # of passengers you wish to cover?
1
2
3
4
5
Declined Passenger Liability
Desired Non-owned Physical Damage Hull Coverage:
$5,000
$10,000
$20,000
$30,000
$40,000
$60,000
$80,000
$100,000
$150,000
$200,000
Decline Physical Damage Coverage
Would you like to receive information about any of these insurance products?
Hangar
Business
Home/Auto
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
Submit
Should be Empty: