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.

Date

Policyholder's Name

Address

Name of Person to Contact

Are you a member of the Soaring Society of America?
YesNo

If yes, please provide your SSA membership #

Occupation/Nature of business

Are you a member of the Aircraft Owners and Pilots Association (AOPA)
YesNo

If yes, please provide your AOPA membership#

Are you just purchasing this aircraft?
YesNo

If no, please Provide the Name of Your Present Insurance Company (not agent)

Policy expiration date

Aircraft Schedule

FAA N#	Year Make & Model	Glider Value	Trailer Value
1.
2.
3.

Pilot 1

Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG)

Total Glider Flights

Total flights in glider with a glide ratio of 35-1 or better

Total Flights in each Make & Model to be Insured

Any physical disabilities that might impact the pilots ability to operate the glider?
YesNo

If yes, please describe:

Pilot 2

Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG)

Total Glider Flights

Total flights in glider with a glide ratio of 35-1 or better

Total Flights in each Make & Model to be Insured

Any physical disabilities that might impact the pilots ability to operate the glider?
YesNo

If yes, please describe:

Pilot 3

Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG)

Total Glider Flights

Total flights in glider with a glide ratio of 35-1 or better

Total Flights in each Make & Model to be Insured

Any physical disabilities that might impact the pilots ability to operate the glider?
YesNo

If yes, please describe:

Comments
Please list any questions or comments below

Thank you for taking the time to complete this form.