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

Is policyholder a member of the Soaring Society of America?
YesNo

Occupation/Nature of business

Present Insurance Company (not agent)

Policy expiration date

Airport Name

Aircraft Schedule

* For Uses R= Rental/Instruction, T= Glider Tow for Hire
Applicable to Gliders and Tow Planes

FAA N#	Year Make & Model	Glider / Tow Plane Value	R	T	Others	Trailer Value
1.			Yes	Yes
2.			Yes	Yes
3.			Yes	Yes

Comments
Please list any questions or comments below

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