Providing Aviation Insurance for More Than 26 Years - Carrio Aviation Insurance - 800.344.4359
 
 
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Aircraft Insurance Application


General Information:
State: Zip:  
   
12:01 AM standard time at the address above
 

 

 
 
Aircraft
Operations other than Paved Public Airports:
Airstrip Length:
Ft. Airstrip Width: Ft. Landing Surface:
Obstructions:
(Fill out this table for First Aircraft) 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
Choose Hangared or Tied Down

Coverage

Insured Value
Choose Flight, Taxi or Storage



$

Deductibles $

$
Lien Holder and Address

Lien Amount

$

Combined Single Limit of Liability
(Bodily injury and Property Damage)

$ Each Occurrence

$ Each Passenger
Medical Payments $ Each Passenger
TOTAL PREMIUM

(Fill out this table for Second Aircraft) 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
Choose Hangared or Tied Down

Coverage

 

Insured Value
Choose Flight, Taxi or Storage

$
Deductibles $

$
Lien Holder and Address

Lien Amount

$

Combined Single Limit of Liability
(Bodily injury and Property Damage)

$ Each Occurrence

$ Each Passenger
Medical Payments $ Each Passenger
TOTAL PREMIUM

(Fill out this table for Third Aircraft) 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
Choose Hangared or Tied Down

Coverage

Insured Value
Choose Flight, Taxi or Storage



$

Deductibles $

$
Lien Holder and Address

Lien Amount

$

Combined Single Limit of Liability
(Bodily injury and Property Damage)

$ Each Occurrence

$ Each Passenger
Medical Payments $ Each Passenger
TOTAL PREMIUM

Pilot Qualifications (List All Pilots Who Will Operate the Aircraft):
(Fill out this table for First Pilot)  
Name
Age
Pilot Certificates and Ratings
(mark Y or N)
Student
PVT
CML
AMEL
Instrum
ATP
Other
Medical Certificate Exp. Date
CLASS
Logged Pilot in Command Hours
Date of Last BFR
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
Total in All Aircraft Past 12 months


(Fill out this table for Second Pilot)  
Name
Age
Pilot Certificates and Ratings
(mark Y or N)
Student
PVT
CML
AMEL
Instrum
ATP
Other
Medical Certificate Exp. Date
CLASS
Logged Pilot in Command Hours
Date of Last BFR
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
Total in All Aircraft Past 12 months


(Fill out this table for Third Pilot)  
Name
Age
Pilot Certificates and Ratings
(mark Y or N)
Student
PVT
CML
AMEL
Instrum
ATP
Other
Medical Certificate Exp. Date
CLASS
Logged Pilot in Command Hours
Date of Last BFR
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
Total in All Aircraft Past 12 months


(Fill out this table for Fourth Pilot)  
Name
Age
Pilot Certificates and Ratings
(mark Y or N)
Student
PVT
CML
AMEL
Instrum
ATP
Other
Medical Certificate Exp. Date
CLASS
Logged Pilot in Command Hours
Date of Last BFR
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
Total in All Aircraft Past 12 months

List All Pilot's claims, incidents, accidents, FAA Medical Waivers (other than for corrective lenses), FAR volations, DUI and felony convictions (or write "NONE"):

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 fraud.”

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 MINNESOTA APPLICANTS: “A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.”

NOTICE TO ARKANSAS 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 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 civil fines and criminal penalties.”

NOTICE TO 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.”

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.

By typing your name here you agree to apply for Aircraft Insurance:

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.

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