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NIM Hull and/or Liability Application
Application for Multiple Aircraft | All Risk Not In Motion Hull and/or Liability
Aircraft Owner:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Expiry:
Insurer:
Home Phone
*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Email Address
*
Fax
Aircraft #1 Details
Aircraft Registration:
*
Year
*
Make & Model
*
# of Seats Excluding Pilot(s)
*
Aircraft is based where (winter/summer):
If Private Strip, please detail surface, length, width, any obstructions:
Aircraft is:
Hangared
Tied Down
Moored
Aircraft Use:
Private Business & Pleasure
Commercial
Other, please explain:
Do you own or lease the hangar?
Yes
No
State Geographic Areas of Operation:
Lienholder/Loss Payee:
Hull Value: if no value, enter 0
*
Rows
$ CAD
Wheels / Helicopter
Skiplane
Floatplane
Amphibian
Aircraft #2 Details (if required)
Aircraft Registration:
Year
Make & Model
# of Seats Excluding Pilot(s)
Aircraft is based where (winter/summer):
If Private Strip, please detail surface, length, width, any obstructions:
Aircraft is:
Hangared
Tied Down
Moored
Aircraft Use:
Private Business & Pleasure
Commercial
Other, please explain:
Do you own or lease the hangar?
Yes
No
State Geographic Areas of Operation:
Lienholder/Loss Payee:
Hull Value:
Rows
$ CAD
Wheels / Helicopter
Skiplane
Floatplane
Amphibian
Aircraft #3 Details (if required)
Aircraft Registration:
Year
Make & Model
# of Seats Excluding Pilot(s)
Aircraft is based where (winter/summer):
If Private Strip, please detail surface, length, width, any obstructions:
Aircraft is:
Hangared
Tied Down
Moored
Aircraft Use:
Private Business & Pleasure
Commercial
Other, please explain:
Do you own or lease the hangar?
Yes
No
State Geographic Areas of Operation:
Lienholder/Loss Payee:
Hull Value:
Rows
$ CAD
Wheels / Helicopter
Skiplane
Floatplane
Amphibian
Coverage Details Aircraft #1
Desired Hull Coverage Aircraft #1:
Not In Motion
Work In Progress
No Hull Coverage
Desired Liability Limit:
Combined Single Limit (Including Passengers) Aircraft #1
$1,000,000
$2,000,000
$3,000,000
None
or
Third Party Bodily Injury and Property Damage Limit - Aircraft #1
$500,000
$1,000,000
$2,000,000
None
Per Passenger Liability Limit
$0
$100,000
$300,000
Required Additional Insureds (Name & Address):
Coverage Details Aircraft #2 (if required)
Desired Hull Coverage Aircraft #2:
Not In Motion
Work In Progress
No Hull Coverage
Desired Liability Limit:
Combined Single Limit (Including Passengers) Aircraft #2
$500,000
$1,000,000
$2,000,000
None
or
Third Party Bodily Injury and Property Damage Limit - Aircraft #2
Optional
Per Passenger Liability Limit
Optional
Required Additional Insureds (Name & Address):
Coverage Details Aircraft #3 (if required)
Desired Hull Coverage Aircraft #3:
Not In Motion
Work In Progress
No Hull Coverage
Desired Liability Limit:
Combined Single Limit (Including Passengers) Aircraft #3
$500,000
$1,000,000
$2,000,000
None
or
Third Party Bodily Injury and Property Damage Limit - Aircraft #3
Optional
Per Passenger Liability Limit
Optional
Required Additional Insureds (Name & Address):
Pilot Details
Pilot Details
Rows
Pilot 1
Pilot 2
Pilot 3
Pilot 4
Pilot 5
Name
Date of Birth (mm/dd/yy):
Type of License \ Permit
Type of Rating(s) \ Endorsement(s)
Accidents, Claims, Incidents or Violations within the last 3 years?
Total Time
Total Flying Time last 12 months
Total Time on Make and Model - Aircraft #1
Total Time on Make and Model - Aircraft #2
Total Time on Make and Model - Aircraft #3
Aircraft to be flown
Do you own a hangar? Would you like a Hangar Quote?
Yes
No
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
Submit
Should be Empty: