Renter/Non-owned Insurance Form Step 1 of 3 33% Select CoveragePersonal Non-Owned CoverageFlight Instructors Personal and Professional Non-Owned CoverageSelect AircraftSingle Engine Piston PoweredMulti-Engine Piston PoweredPiston Powered RotorcraftSingle Engine Sea PlaneSelect Affiliation (if any)Society of Aviation and Flight Educators (SAFE)In the last 3 years have you been involved in... Any aircraft accidents, losses or claimes? FAA Violations? Been convicted of a DUI or crime classified as a felony? Been cancelled or declined or refused an aircraft insurance policy? (For Flight Instructors) Do you hold a Master CFI designation or do you currently hold a CSIP designation? Yes No (Training Last 12 Months) Completed a FAA Basic, Advanced or Wings Program? Hangared Tied Down Lienholder Yes No Is aircraft on floats? Yes No Pilot InformationDo you maintain or repair aircraft other than aircraft owned or leased by you? Yes No Do you have care or control of aircraft not owned or leased by you? Yes No Do you sell fuel? Yes No Do you operate aircraft you own or lease? Yes No Do you sell aircraft parts (not installed)? Yes No Any accients, waivers, losses, violations, incidents, claims in the past 5 years? Yes No If you answered yes to the previous question, explain below:Are you responsible for maintaining the airport? Yes No Do you own hangar(s)? Yes No Do you need Workers Compensation coverage? Yes No How may years have you been in business? Locations- Provide address and airport identifiersWhen does your current insurance policy expire? Your Name(Required) First Last Business Name Website Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country CoveragesLiability Limit Requested$1,000,000 per occurrence/ $100,000 per passenger$1,000,000 Combined Single LimitOther (If checked, enter amount below)Specific Limit Requested Type of UsePersonal Business and Pleasure/Non-CommercialOther (please provide details in the additional information section belowAdditional InformationHow did you hear about us? Consent I agree to the privacy policy.UntitledFirst ChoiceSecond ChoiceThird Choice 16369
