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PERSONAL PLEASURE & BUSINESS FIXED- WING AIRCRAFT INSURANCE (Risk Placement Services, Inc.)

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APP-10 (03.2005)
Insurance Provided by
Member Companies of
American International Group, Inc.
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.
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: _____________________________ Number hrs. per year: ________________
Has any insurance company cancelled or refused to renew your aircraft insurance? YES NO (Missouri applicants do not respond)
If YES, explain: ____________________________________________________________________________________________
___________________________________________________________________________________________________________
Expiration date of current insurance: ______________________________________________________________________________
Name of current insurance company: _____________________________________________________________________________
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
Hangared
Tied Down
Hangared
Tied Down
Hangared
Tied Down
COVERAGE
Insured Value $
Flight Taxi
Storage
$
Flight Taxi
Storage
$
Flight Taxi
Storage
Deductibles $
Not-In-Motion
In-Motion
$
Not-In-Motion
In-Motion
$
Not-In-Motion
In-Motion
Lien Holder
and Address
Lien
Amount $
Loss Payee Only
Breach of Warranty
$
Loss Payee Only
Breach of Warranty
$
Loss Payee Only
Breach of Warranty
Combined Single Limit of
Liability (Bodily Injury and
Property Damage)
$
Each
Occurrence
Excluding Passengers
Including Passengers
limited to $_______ Each
Passenger
$
Each
Occurrence
Excluding Passengers
Including Passengers
limited to $_______ Each
Passenger
$
Each
Occurrence
Excluding Passengers
Including Passengers
limited to $_______ Each
Passenger
Medical
Payments $
Each Passenger
$
Each Passenger
$
Each Passenger
TOTAL PREMIUM $ $ $
PERSONAL PLEASURE & BUSINESS FIXED-
WING AIRCRAFT INSURANCE APPLICATION
APP-10 (03.2005)
PILOT QUALIFICATIONS (List all pilots who will operate the aircraft.)
Pilot Certificates &
Ratings
Medical
Certificate Logged Pilot in Command Hours
Name Age
Student
PVT.
CM’L
AMEL
Instrum
ATP
Other
Exp .
Date Class
Date
Last
B.F.R.
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
Months
/
/
/
/
/
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. ________________________________________________________________
____________________________________________________________________________________________________________
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 subjects such person 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, 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 f raud.
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 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.
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 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 in the third degree.
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 policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Authorities.
NOTICE TO ARKANSAS AND NEW MEXICO 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 UTAH APPLICANTS: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or
fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional
services 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 TENNESSEE AND VIRGINIA 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 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 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 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 S.S. 3613.1)
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. 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.
Applicant Signature Today’s Date
To Be Completed By Producer
Producer: ___________________________________________________________________________________________________
Address:______________________________________________________
City: ___________
State: ______
Zip: ________
Telephone Number: ______________ Fax Number: _________________
E-mail: ______________________________________
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Completed 30 July 2020

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