Aviation Insurance Application
Schrager Hampson Aviation Insurance Group
Applicant is
*
Individual
Business
Insured Name
*
First Name
Last Name
Insured Business Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
Coverage Effective Date
*
-
Month
-
Day
Year
Date
Additional Interests
Is Applicant Sole Owner of Aircraft?
*
Yes
No
If No, Explain:
Is Breach of Warranty Required (Is there a Lien on the aircraft)?
*
Yes
No
Name of Lienholder
Address Of Lienholder
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lien Amount ($)
Aircraft Information
Aircraft 1
*
Rows
N Number
Year
Make & Model
Insured Value
Total Seats
Hangared? (Y/N)
Home Base Airport Identifier
Land Plane (Y/N)
TSMOH
Aircraft
Add Additional Aircraft?
*
Yes
No
Aircraft 2
*
Rows
N Number
Year
Make & Model
Insured Value
Total Seats
Hangared? (Y/N)
Home Base Airport Identifier
Land Plane (Y/N)
TSMOH
Aircraft
Aircraft 3
Rows
N Number
Year
Make & Model
Insured Value
Total Seats
Hangared? (Y/N)
Home Base Airport Identifier
Land Plane (Y/N)
TSMOH
Aircraft
Annual Utilization (hours)
Requested Liability Limit
*
1,000,000 per occurrence, $100,000 sublimit per passenger
1,000,000 per occurrence, $200,000 sublimit per passenger
1,000,000 per occurrence, $1,000,000 sublimit per passenger
2,000,000 per occurrence, $200,000 sublimit per passenger
2,000,000 per occurrence, $2,000,000 sublimit per passenger
Medical Payments Limit
*
$5,000
$10,000
$20,000
Pilot Information
Pilot Name
*
First Name
Last Name
Pilot Date of Birth
*
Medical Class
*
Please Select
1st
2nd
3rd
Basic Med
None
Medical Issuance Date:
-
Month
-
Day
Year
Date
Limitations:
*
Certificate, Endorsements, and Ratings
*
Student
Private
Commercial
Airline Transport Pilot
Instructor
Instrument Rating
Helicopter
Sea Plane
Single Engine Land
Single Engine Sea
Multi-engine Land
Multi-engine Sea
Center Line Thrust
Glider
Airframe Technician
Powerplant
Inspection Authorization
Other
Hours Logged by Category
*
Rows
Total Hours
Land
Piston Sea
Amphib
Turboprop
Jet
Single Engine - Fixed Wing
Multi-Engine - Fixed Wing
Rotor Wing
Experience by Make and Model
*
Rows
Make and Model Name
Total Hours
Last 12 Months
1
2
3
4
5
6
7
8
Number of water landings last 12 months:
*
Tailwheel Hours:
*
Retract Hours:
*
Turbine AG Hours:
*
Date of last biennial or annual flight review:
-
Month
-
Day
Year
Date
Date of last IPC
-
Month
-
Day
Year
Date
School Attended
Date School Attended
-
Month
-
Day
Year
Date
Has this pilot ever had any aviation claims, incidents, accidents, FAR violations DUI's, felony convictions, or been under indictment?
*
Yes
No
If "Yes" Explain:
Does anyone else fly your aircraft regularly? (add another pilot)
*
Yes
No
If yes, list their name(s)
Link to Pilot History Form will show on Thank You Page Upon Submission
Operations
Use of Aircraft: "Pleasure and Business" meaning used in the applicant's business, including personal and pleasure uses, but excluding any operation for hire or reward.
*
Pleasure & Business
Industrial Aid (Pro-Flown Business and Leisure Flights)
Commercial Aerial Survey
Commercial Instruction & Rental
Charter
Sightseeing
Other
Will the aircraft be operated at other than paved public airports?
*
Yes
No
If Yes, where and how often?
Will the aircraft be operated outside the 48 contiguous states?
*
Yes
No
If Yes, Explain:
Does the aircraft have other than a standard airworthiness certificate?
*
Yes
No
If Yes, Explain:
Has the aircraft been modified or converted in any way from the manufacturer's original configuration or design in such a manner to have required a Supplemental Type Certificate (STC)?
*
Yes
No
If Yes, Explain:
Memberships & TAA
Aircraft meets the FAA definition of TAA aircraft including an IFR approved GPS, moving map display, and 2-axis autopilot.
Yes
No
AOPA #
EAA #
Warranties
Has the applicant ever had any aviation claims, incidents, accidents, FAR violations DUI's, felony convictions, or been under indictment?
*
Yes
No
If Yes, Explain:
I certify that the statements in this form are true to the best of my knowledge and belief, and I have not knowingly or intentionally concealed any pertinent information.
*
First Name
Last Name
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: