Aviation Insurance Quote 3

Heffernan Insurance Brokers

Aviation Insurance Request Form

Please complete the form below, and one of our team members will reach out to discuss your aviation insurance needs.

Policyholder's Information

Registered Owner(s)

Occupation of each Owner

Street Address

City

State

Zip

Contact Information for Person Handling Insurance

First Name

Last Name

Work Phone

Home Phone

Fax

How did you hear about us?

Is this a new purchase? If not provide current insurance company data below.
YesNo

Present Insurance Company (not broker)

Policy Expiration Date

AOPA Number

Member Name

Aircraft Data

N#?

Year?

Make?

Model?

Total Seats?

Desired Insured Value($)

Based at What Airport?

Airport's Identifier?

Stored

Use
Industrial Aid (Pro Pilot Flown Only)Pleasure and Non-Commercial Business (Non Pro Flown)Instruction and Rental for HireCharter CommercialInstruction/Rental/CharterOther

Is or will there be a lienholder?

Amount of Loan?

Pilot Information

	Pilot 1	Pilot 2	Pilot 3
First Name
Last Name
Age
License Type
Does pilot have a Type Rating for this aircraft?	YesNoNot Required	YesNoNot Required	YesNoNot Required
Ratings (Please choose all that apply)	IFRSEAMulti-EngineRotorCFI	IFRSEAMulti-EngineRotorCFI	IFRSEAMulti-EngineRotorCFI
Name of Factory School Completed for this aircraft?
Date last attended?
	Factory School Not Required	Factory School Not Required	Factory School Not Required

Logged Pilot Hours

	Pilot 1	Pilot 2	Pilot 3
Total Logged Hours
Total hours in this model
Retractable Gear Time (if applicable)
Multi-Engine Time (if applicable)
Tailwheel Time (if applicable)
Turboprop Time (if applicable)
Pure Jet Time (if applicable)
Rotor Time (if applicable)
Seaplane Time (if applicable)
Others
Hours flown in all aircraft in last 12 Months

Liability Limits Requested

$1,000,000 Combined Single Limit including $100,000 per passenger.$1,000,000 Combined Single Limit with no passenger limitation.Other (please specify below):

All pilots above have a valid and effective pilot certificate?
YesNo
For all pilots, please list any aviation accidents, waivers, violations, losses, incidents, DUI or DWI’s below: Give dates and details. If none, say none in the box below.

Any flights out of the United States anticipated? If yes, please list countries below.

Comments
Please list any questions or comments below

Thank you for taking the time to complete this form.

Heffernan Insurance Brokers

Policyholder's Information

Contact Information for Person Handling Insurance

Aircraft Data

Pilot Information

Logged Pilot Hours

Liability Limits Requested

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