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Personal, Pleasure and Competition Glider Insurance Needs.
Date

Policyholder's Name

Address

Name of Person to Contact

Present Insurance Company (not agent)

Policy expiration date

Name of Airport

City and State

Comments
Please describe the nature of your business:

Please Check the Box Next to Your Desired Coverages

Slip and fall on your premises - Airport Premises Liabiliy CoverageSale of aircraft, fuel, etc.- Products Liability CoverageBailment of aircraft you do not own, lease or consign - Ground Hangarkeepers Liability CoverageMinor injuries on your premises - Premises Medical CoverageOperation of owned, leased or consigned aircraft - Owned Aircraft Liability and Hull Insurance CoverageOperation of aircraft you do not own, lease or consign - Non-Owned Aircraft Liability and Hull Insurance CoverageFire on Building and/or Contents - A Property Insurance Policy

Do you own or lease any aircraft?
YesNo

Thank you for taking the time to complete this form.