Avinsure Agency Inc. - Online Application

To submit an online application for an insurance estimate, please fill out the information below as completely and accurately as possible. Once submitted, an insurance agent will be in touch with you as quickly as possible.

Please provide the following applicant information

Name:
Title:
Occupation:
Address:
City:

State/Province:
Zip Code:
Work Phone:
Home Phone:
Fax:
E-mail:
Expiration Date of Present Insurance:		(mm/dd/yyyy)
Present Insurance Company:

(If you are entering more than one aircraft below please ensure that the aircraft make field for each plane is filled in or all other fields for that aircraft will not be recorded.)

Please provide the following aircraft information for your first aircraft:

Aircraft Make:*
Aircraft Model:
Year:
Registration Number:
Present Estimated Value:
Aircraft's Usual Base:
Aircraft Liability:
Hangared -or- Tied-out

Please provide the following aircraft information for your second aircraft:

Aircraft Make:*
Aircraft Model:
Year:
Registration Number:
Present Estimated Value:
Aircraft's Usual Base:
Aircraft Liability
Hangared -or- Tied-out

Please provide the following aircraft information for your third aircraft:

Aircraft Make:*
Aircraft Model:
Year:
Registration Number:
Present Estimated Value:
Aircraft's Usual Base:
Aircraft Liability:
Hangared -or- Tied-out

Please provide the following aircraft information for your fourth aircraft:

Aircraft Make:*
Aircraft Model:
Year:
Registration Number:
Present Estimated Value:
Aircraft's Usual Base:
Aircraft Liability:
Hangared -or- Tied-out

Please identify and describe each pilot who will fly aircraft:

First Pilot's Name:
Age:
Occupation:
Type of License:
Ratings:
Total Time Hours:
Make & Model Hours:
Retractable Gear Hours:
M.E. Hours:
T.W. Hours:
Hours Last 12 Months:

Any Losses, Waivers, DUIs, Suspensions, Accidents or Violations or Regulations for First Pilot?
Yes. No. -- If Yes please explain briefly below:

Second Pilot's Name:
Age:
Occupation:
Type of License:
Ratings:
Total Time Hours:
Make & Model Hours:
Retractable Gear Hours:
M.E. Hours:
T.W. Hours:
Hours Last 12 Months:

Any Losses, Waivers, DUIs, Suspensions, Accidents or Violations or Regulations for First Pilot?
Yes. No. -- If Yes please explain briefly below:

Third Pilot's Name:
Age:
Occupation:
Type of License:
Ratings:
Total Time Hours:
Make & Model Hours:
Retractable Gear Hours:
M.E. Hours:
T.W. Hours:
Hours Last 12 Months:

Any Losses, Waivers, DUIs, Suspensions, Accidents or Violations or Regulations for First Pilot?
Yes. No. -- If Yes please explain briefly below:

Fourth Pilot's Name:
Age:
Occupation:
Type of License:
Ratings:
Total Time Hours:
Make & Model Hours:
Retractable Gear Hours:
M.E. Hours:
T.W. Hours:
Hours Last 12 Months:

Any Losses, Waivers, DUIs, Suspensions, Accidents or Violations or Regulations for First Pilot?
Yes. No. -- If Yes please explain briefly below:

Other additional helpful information