Name of Applicant(s) __________________________________________________________________________________________
Applicant’s Address ___________________________________________________________________________________________
Applicant’s Telephone Numbers: Home ___________________________________ Work _________________________________
Business or Occupation of Applicant(s)____________________________________________________________________________
Coverage Effective from ______________________ until________________________ 12:01 AM standard time at the address above
Applicant is the sole owner of the aircraft, other than _________________________________________________________________
Are any other aircraft owned by, rented or used by or on behalf of Applicant? _____________________________________________
Model aircraft_____________________ Uses__________________ No. of hours per year _____________________
Has any insurance company cancelled or refused to renew your aircraft insurance?
n
No
n
Yes
Note: Missouri Applicants. Do not respond)
Please Explain ______________________________________________________________________________________________
Expiration Date of current insurance ______________ Name of current Insurance Company __________________________________
PERSONAL PLEASURE & BUSINESS
FIXED-WING AIRCRAFT
.
INSURANCE APPLICATION
AIRCRAFT
Operations other than Paved Public Airports:
Airstrip Length ____________ Ft. Airstrip Width___________Ft. Landing Surface_____________ Obstructions_______________
________________________________________________________________________________
N# N# N#
________________________________________________________________________________
Year Make & Model
__________________________________________________________________________________________________________
Total Seats
__________________________________________________________________________________________________________
Annual Hours Flown
__________________________________________________________________________________________________________
Date of Last Annual
__________________________________________________________________________________________________________
Engine Make & Model
and
Hours Since Overhaul
__________________________________________________________________________________________________________
Describe "Airworthiness"
Certificates Other than Standard
__________________________________________________________________________________________________________
Describe Aircraft Modifications
or Unrepaired Damage
__________________________________________________________________________________________________________
Airport Name
(Location)
City, State
________________________________________________________________________________________________________
CONTINUED ON REVERSE SIDE
n
Hangared
n
Tied Down
n
Hangared
n
Tied Down
n
Hangared
n
Tied Down
Separate application is required for all other aircraft (sailplanes, helicopters, etc.,) and/or uses (special/commercial)
There is no coverage if you make any charge, receive any money or any other compensation or reward for use of your aircraft, other than sharing the cost of
fuel, oil, landing fees, customs fees or temporary parking for a flight with your passengers. Please contact your insurance agent instead of using this form.
TECHNOLOGICAL ADVANCEMENTS:
Note the aircraft listed above that contain an IFR approved GPS, moving map display and two or more axis autopilot:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Note the aircraft listed above that have terrain awareness, traffic avoidance, fuel totalizer, RNP, WX monitoring
(lightning, data link or radar).
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
What was the date of completion of Instrument Proficiency Check: ______________________________________________________
List ASF course completion by title and date: _______________________________________________________________________
APP-10 (rev 03/18)
Chartis Aerospace
Insurance Services, Inc
AIG Aerospace
Insurance Services, Inc.
COVERAGE
Insured Value $$ $
________________________________________________________________________________________________
$$ $
Deductibles $$ $
________________________________________________________________________________________________
Lien Holder
and
Address
__________________________________________________________________________________________________________
Lien Amount $$ $
__________________________________________________________________________________________________________
Combined Single Limit of
Liability (Bodily Injury and
Property Damage)
$ Ea. Occurrence $ Ea. Occurrence $ Ea. Occurrence
n
Excluding Passengers
n
Excluding Passengers
n
Excluding Passengers
n
Including Passengers limited to
n
Including Passengers limited to
n
Including Passengers limited to
$ Ea. Passenger $ Ea. Passenger $ Ea. Passenger
___________________________________________________________________________________________________________
Medical Payments $ Ea. Passenger $ Ea. Passenger $ Ea. Passenger
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
PILOT QUALIFICATIONS
Pilot Certificates and Ratings
Name
Age
STUDENT
CLASS
Expiration
Date
Date of
Last
B.F.R.
.PVT
CM'L
AMEL
Inst
ATP
Other
Logged Pilot in Command Hours
Medical
Certificate
Total
Time
Total
R/G
Total
M/E
Total
Tail
Wheel
Other
Total
In Aircraft
Model to
be Insured
Total in All
Aircraft Past
90 Days / 12 Mos
/
/
/
/
(LIST ALL PILOTS WHO WILL OPERATE THE AIRCRAFT)
List all Pilot’s claims, incidents, accidents, FAA Medical Waivers (other than for corrective lenses), FAR violations, DUI and felony convictions
(write “none” if none of the above applies)
n
Flight
n
Taxi
n
Storage
n
Not-In-Motion
n
In-Motion
n
Not-In-Motion
n
In-Motion
n
Not-In-Motion
n
In-Motion
n
Flight
n
Taxi
n
Storage
n
Flight
n
Taxi
n
Storage
n
Loss Payee Only
n
Breach of Warranty
n
Loss Payee Only
n
Breach of Warranty
n
Loss Payee Only
n
Breach of Warranty
Would you like a Private Client Group representative to contact you regarding your personal life insurance? YES NO
q q
APP-10 (rev 03/18)
PAGE 2
FRAUD WARNINGS (Last updated 6/15)
NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION
OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A
FRAUDULENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO ALABAMA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A
LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME
AND MAY BE SUBJECT TO RESTITUTION FINES OR CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF.
NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY.
PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR
AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A
POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE
FRAUD WARNINGS CONTINUED
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING
INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE
IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION
MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
NOTICE TO KANSAS APPLICANTS:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED
OR PREPARED WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR
ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY
FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE
POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIAL FALSE INFORMATION
CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING
ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT
OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME
AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A
DENIAL OF INSURANCE BENEFITS.
NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST
AN INSURER IS GUILTY OF A CRIME.
NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN
APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM
CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT
TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD
AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF
INSURANCE FRAUD.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE
ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR
MISLEADING INFORMATION IS GUILTY OF A FELONY (365:15-1-10, 36 §3613.1).
NOTICE TO OREGON APPLICANTS:
1. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR,
CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE GUILTY
OF A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
2. WHERE THE WORD WARRANT AND WARRANTED ARE USED, THEY ARE REPLACED BY REPRESENT AND REPRESENTED.
NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY
OR OTHER PERSON FILES
AN
APPLICATION FOR
INSURANCE OR
STATEMENT
OF
CLAIM
CONTAINING ANY
MATERIALLY
FALSE
INFORMATION
OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO
COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APP-10 (
rev
03
/18)
PAGE 3
(Producer will fill in this information)
Producer ___________________________________________________________________________________________________
Address___________________________________________________________________________________________________ City _____________________ State ____________ Zip ______________
Telephone No.____________________________ Fax No. _________________________________________________________
Email Address ____________________________________________________________
APP-10 (rev 03/18)
PAGE 4
This Application does not commit the Company to any liability nor make the Applicant liable for any premium unless and until the Company
agrees in writing to effect this insurance.
X _______________________________________________________________ __________________________________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Applicant's Signature Today's Date
NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR
MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR
INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
ALL INFORMATION HEREIN IS WARRANTED TO BE TRUE TO THE BEST OF MY KNOWLEDGE AND NO INFORMATION HAS BEEN
SUPPRESSED OR WITHHELD, AND *NO INSURER HAS CANCELLED OR REFUSED TO RENEW THIS INSURANCE (*NOT
APPLICABLE IN MISSOURI). I
UNDERSTAND THAT THE INFORMATION HEREIN AND THE TRUTHFULNESS THEREOF WILL BE THE BASIS OF ANY INSURANCE PROVIDED
BY THE COMPANY. THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY TO PROVIDE ANY INSURANCE.
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