Contact Information   Last Name First Name Occupation AOPA Membership # City State Phone (Home) Phone (Work) Fax E-Mail Preferred Method Of Contact Work PhoneHome PhoneE-MailFax Aircraft Information   Aircraft Is Registered In My Personal NameHolding Corp or LLCIn My Company's Name Specify Company Name (if applicable) FAA # N- Year Aircraft Make Aircraft Model Aircraft Based - Airport Name Aircraft Based - Airport Identifer Aircraft Stored In HangarTied Down Current Insurance Company New Purchase AIG Aviation Aerospace (ANPAC) Avemco Global Aerospace-AAU Phoenix (Old Republic) USAIG - USAU US Specialty W Brown (XL Specialty) None Current Policy Expiration Date 0-30 days31-60 days61-90 days91 days or moreNew Purchase Aircraft Coverage Information   Liability Limits $1,000,000 per occurrence limited To $100,000 per passenger $1,000,000 Combined Single Limit (CSL) per occurrence including passengers$2,000,000 Combined Single Limit (CSL) per occurrence including passengers Other - List Desired Liability Limit below in Comments section Insured Hull Value $ Aircraft Usage Pleasure & Business Only - Owner Flown Part 91 - Pro-Pilot Flown Part 135 - On Demand Charter Commercial Flight Instruction Other - List other usages in the Comments section Pilot Information   Pilot #1 Name Age License  PrivateCommercialATPStudent Ratings  ASELAMEL Instrument Rated  YesNo Total Hours PIC in All Aircraft Total Hours in Make/Model To Be Insured Total Hours in Retractable-Gear Aircraft Total Hours in Multi-Engine Aircraft Total Hours in Tailwheel Aircraft Total Hours in Last 12 Months Date of Last Medical Certificate 0-12 Months13-24 MonthsExpired Date of Last BFR 0-12 Months13-24 MonthsExpired Pilot #2  PrivateCommercialATPStudent  ASELAMEL  YesNo 0-12 Months13-24 MonthsExpired 0-12 Months13-24 MonthsExpired Pilot #3  PrivateCommercialATPStudent  ASELAMEL  YesNo 0-12 Months13-24 MonthsExpired 0-12 Months13-24 MonthsExpired Have Any Pilots Above Had Any Aircraft Accidents, Incidents, DUIs, FAA Violations, License Suspensions, or Medical Waivers (other than corrective lenses)? NoYes - please explain below Additional Comments Please list any additional information you would like to add including any Recurrent Training Courses completed or Date of last IPC/ICC, Type Ratings, etc.