Harmon Insurance & Bonding Agency
Aviation Insurance Application
Name:
Address:
City:
State:
AL
AK
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Email:
Business
#
Fax #
Home
#
Aircraft:
N Number:
Make:
Model:
Year:
Total # Seats:
Airport where Based:
Hangared:
Tied Down:
Second aircraft, send form, then change information and re-send.
Use:
P & B:
Ag:
Rental:
Instruction:
Charter:
Cargo:
Other:
Territorial Requirements:
Value:
Aircraft $
Spare Engine $
Liability:
Property Damage: $
Bodily Injury Ground: $
Total Passengers: $
Per Seat: $
Registered Owner:
Same:
Name:
Address:
City:
State:
County:
Country:
Zip:
Mortgagee:
Address:
City:
State:
County:
Zip:
Current Insurance Company:
Exp. Date:
Pilot:
Date Of Birth:
License:
Student
Private
Commerical
ATP
Ratings:
Instrument
Multi engine
CF I
CF II
Rotor
Sea Plane
Instructor
Hours:
Total Time
This make and model:
Tail Dragger:
Retractable Gear:
Jet:
Multi-Engine:
Turbo Prop:
A2 Time:
Pressurized:
Schools:
Simulator
Yes
No
School:
When:
FAA Wings Program:
Yes
No
Phases Completed:
Physical:
Date of Last
Date last biannual flight review
Second Pilot submit form, then change pilot data and re-send.
Date of last A/C accident:
None
Felony, DUI or Any FAA Violations or Waiver (except eye glasses):
Yes
No
Explanation if yes:
Remarks:
Be Sure - Insure With Us
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