Language
English (Canada)
French (Canada)
Private Aircraft Application
All Risk In Motion & Not In Motion Hull and Liability
Aircraft Owner:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Expiry:
Insurer:
Home Phone
*
Work Phone
Cell Phone
*
Email Address
*
Fax
Membership #
Aircraft #1 Details
Aircraft Registration #1:
*
Year
*
Make & Model
*
# of Seats Excluding Pilot(s)
*
Aircraft is based where (winter/summer):
*
Does the aircraft have conventional gear?
*
Yes
No
Retractable landing gear?
*
Yes
No
Has the aircraft had any claims in the last 5 years?
No
Yes
If yes, please explain
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:
*
Additional Insured:
*
Hull Value: if no value, enter 0
*
$ CAD
Wheels / Helicopter
Skiplane
Floatplane
Amphibian
Does the value represent present market value (including applicable taxes)?
Yes
No
If not, the amended value is:
*
Reason
*
Aircraft #2 Details (if required)
Aircraft Registration #2:
Year
Make & Model
# of Seats Excluding Pilot(s)
Aircraft is based where (winter/summer):
Does the aircraft have conventional gear?
Yes
No
Retractable landing gear?
Yes
No
Has the aircraft had any claims in the last 5 years?
No
Yes
If yes, please explain
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:
Additional Insured:
Hull Value: if no value, enter 0
$ CAD
Wheels / Helicopter
Skiplane
Floatplane
Amphibian
Does the value represent present market value (including applicable taxes)?
Yes
No
If not, the amended value is:
Reason
Aircraft #3 Details (if required)
Aircraft Registration #3:
Year
Make & Model
# of Seats Excluding Pilot(s)
Aircraft is based where (winter/summer):
Does the aircraft have conventional gear?
Yes
No
Retractable landing gear?
Yes
No
Has the aircraft had any claims in the last 5 years?
No
Yes
If yes, please explain
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:
Additional Insured:
Hull Value: if no value, enter 0
$ CAD
Wheels / Helicopter
Skiplane
Floatplane
Amphibian
Does the value represent present market value (including applicable taxes)?
Yes
No
If not, the amended value is:
Reason
Coverage Details
Desired Hull Coverage for all aircraft:
In Motion & Not In Motion
Not In Motion
No Hull Coverage
Desired Liability Limit for all aircraft:
Combined Single Limit (Including Passengers)
*
$1,000,000
$2,000,000
$3,000,000
N/A - choosing an option below
or
Third Party Bodily Injury and Property Damage Limit
*
$500,000
$1,000,000
$2,000,000
N/A - chose an option above
Other - if other, please explain.
Per Passenger Liability Limit
*
$0
$100,000
$300,000
N/A - chose an option above
Pilot Details
Pilot Details
Pilot 1
Pilot 2
Pilot 3
Pilot 4
Pilot 5
Name
Aircraft to be Flown
Occupation
Date of Birth (mm/dd/yy)
Type of License \ Permit
Type of Rating(s) \ Endorsement(s)
Accidents, Claims, Incidents or Violations within the last 5 years?
Proficiency Training in the Last 12 Months
Total Time
Total Time on Make and Model of Aircraft #1
Total Time on Make and Model of Aircraft #2 (if applicable)
Total Time on Make and Model of Aircraft #3 (if applicable)
Total Time Floats
Total Time Amphibian
Total Time Retractable
Total Time Taildragger
Total Time Skis
Total Time Multi Engine
Total Time Turbine
Total Time Rotary
Time on Make & Model last 90 days
Time on Make & Model last 12 months
Total Flying Time last 12 months
Would you like to receive information about any of these insurance products?
Hangar
Business
Life
Home/Auto
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
Submit
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