Welcome to Falcon Insurance Agency | Nation Wide Aviation Insurance

General Information

Registered Owner

Contact Name

Contact Address

Contact City

Contact State

Contact Zip

Contact Phone

Contact Alternate Phone

Contact Fax

Contact Occupation

Do you currently have a policy?

Yes No New Purchase

Are you a member of any of the following? (If none, leave blank)

ABS CPA EAA MAPA PPA SPA USAA

Are you a AOPA member?

Yes No

Is this aircraft a Seaplane?

Yes No

Does your Aircraft use Skis during the year?

Yes No

Is your Aircraft laid-up (Stored) for a specific period during the year?

Yes No

Member Information

ABS Member Number

CPA Member Number

EAA Member Number

MAPA Member Number

PPA Member Number

SPA Member Number

USAA Member Number

AOPA Member Number

Current Insurance Company

Current Policy Begin Date

Current Policy End Date

Aircraft Information

Aircraft Use

Description of Commercial Aircraft Use

Aircraft Year/Make/Model

Engine Make/Model

Gear Configuration

Tri-Gear Tail Wheel Retractable

Airport ID or Name of Airport & Location

Runway Length

Surface Material

Hangared or Tied

Hangared Tied Neither

Number of Pilots

One Two Three

FAA Number

Total Seats

Agreed Hull Value

Limits of Liability

If other Liability, please explain

Year, Make & Model of Floats

Value of Floats (separate from Hull)

Aircraft on Floats Begin Date

Aircraft on Floats End Date

Make & Model of Skis

Value of Skis (separate from Hull)

Aircraft on Skis Begin Date

Aircraft on Skis End Date

Aircraft Laid-up Begin Date

Aircraft Laid-up End Date

Lien Information

Does your Aircraft have a lien

Yes No

Lienholder Name

Lienholder Address

Lienholder City

Lienholder State

Lienholder Zip

Lienholder Phone

Lienholder Fax

Lien Amount

Pilot 1 Information

Pilot One Name

Pilot One D.O.B

Pilot One Age

Pilot One Certificates

ATP Commercial Private Student Recreational Sport

Pilot One Ratings

Instruments Helicopter CFI Single Engine Land Multi Engine Land Single Engine Sea Multi Engine Sea Glider

Pilot One Total Hours

Pilot One Total Hours Last 12 Months

Pilot One BFR Date

Pilot One Medical Date

Pilot One Make & Model Hrs

Pilot One Make & Model Hrs Last 12 Months

Pilot One Retractable Gear Hrs

Pilot One Multi Engine Hrs

Pilot One Tail Wheel Hrs

Pilot One Glider Hrs

Pilot One Turbo Prop Hrs

Pilot One Jet Hrs

Pilot One Rotorwing Hrs

Pilot One SeaPlane Last 12 Months Hrs

Pilot One Seaplane Last 3 Months Hrs

Pilot One Single Engine Sea Hrs

Pilot One Multi Engine Sea Hrs

Pilot One Amphibian Hrs

Pilot One Alaska Hrs

Pilot One Make/Model Land Hrs

Pilot One Make/Model Sea Hrs

Pilot One Recurrent Training

Yes No

Pilot One Completed Sea Wings Program

Yes No

Pilot One Recurrent Training Completion Date

Pilot One Completion of Sea Wings Program Date

Pilot One Dual Flight Instruction Logged

Pilot One flight schools, recurrency and specific training

Pilot One losses, waivers, violations, cancellations or DWI's

Pilot 2 Information

Pilot Two Name

Pilot Two D.O.B

Pilot Two Age

Pilot Two Certificates

ATP Commercial Private Student Recreational Sport

Pilot Two Ratings

Instruments Helicopter CFI Single Engine Land Multi Engine Land Single Engine Sea Multi Engine Sea Glider

Pilot Two Total Hours

Pilot Two Total Hours Last 12 Months

Pilot Two BFR Date

Pilot Two Medical Date

Pilot Two Make & Model Hrs

Pilot Two Make & Model Hrs Last 12 Months

Pilot Two Retractable Gear Hrs

Pilot Two Multi Engine Hrs

Pilot Two Tail Wheel Hrs

Pilot Two Glider Hrs

Pilot Two Turbo Prop Hrs

Pilot Two Jet Hrs

Pilot Two Rotorwing Hrs

Pilot Two SeaPlane Last 12 Months Hrs

Pilot Two Seaplane Last 3 Months Hrs

Pilot Two Single Engine Sea Hrs

Pilot Two Multi Engine Sea Hrs

Pilot Two Amphibian Hrs

Pilot Two Alaska Hrs

Pilot Two Make/Model Land Hrs

Pilot Two Make/Model Sea Hrs

Pilot Two Recurrent Training

Yes No

Pilot Two Completed Sea Wings Program

Yes No

Pilot Two Recurrent Training Completion Date

Pilot Two Completion of Sea Wings Program Date

Pilot Two Dual Flight Instruction Logged

Pilot Two flight schools, recurrency and specific training

Pilot Two losses, waivers, violations, cancellations or DWI's

Pilot 3 Information

Pilot Three Name

Pilot Three D.O.B

Pilot Three Age

Pilot Three Certificates

ATP Commercial Private Student Recreational Sport

Pilot Three Ratings

Instruments Helicopter CFI Single Engine Land Multi Engine Land Single Engine Sea Multi Engine Sea Glider

Pilot Three Total Hours

Pilot Three Total Hours Last 12 Months

Pilot Three BFR Date

Pilot Three Medical Date

Pilot Three Make & Model Hrs

Pilot Three Make & Model Hrs Last 12 Months

Pilot Three Retractable Gear Hrs

Pilot Three Multi Engine Hrs

Pilot Three Tail Wheel Hrs

Pilot Three Glider Hrs

Pilot Three Turbo Prop Hrs

Pilot Three Jet Hrs

Pilot Three Rotorwing Hrs

Pilot Three SeaPlane Last 12 Months Hrs

Pilot Three Seaplane Last 3 Months Hrs

Pilot Three Single Engine Sea Hrs

Pilot Three Multi Engine Sea Hrs

Pilot Three Amphibian Hrs

Pilot Three Alaska Hrs

Pilot Three Make/Model Land Hrs

Pilot Three Make/Model Sea Hrs

Pilot Three Recurrent Training

Yes No

Pilot Three Completed Sea Wings Program

Yes No

Pilot Three Recurrent Training Completion Date

Pilot Three Completion of Sea Wings Program Date

Pilot Three Dual Flight Instruction Logged

Pilot Three flight schools, recurrency and specific training

Pilot Three losses, waivers, violations, cancellations or DWI's

General Quote Multiple Pilots

General Information

Member Information

Aircraft Information

Lien Information

Pilot 1 Information

Pilot 2 Information

Pilot 3 Information

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