ࡱ> ^`] "bjbj "Zjjl& & & 8^ D \H W|OQQQQQQ$ "uK|WKKuK"OKO ڜT & mjt0H.#.#Application for Non-Owned Aircraft Personal Liability and Aircraft Damage Liability (This coverage is not available to residents of Alaska or Hawaii) This application is for Personal Renters and Flight Instructors. I desire insurance to cover my activities as a (Select One)  FORMCHECKBOX  Personal Renter This application is for your personal and business related use of non-owned, fixed wing, non-pressurized, land aircraft having non-turbine single engine of 450 horsepower or less (including non-powered sailplanes) and a capacity of no more than seven (7) total passengers and/or seats and having standard airworthiness certificate.  FORMCHECKBOX  Flight Instructor This application is for your personal, business related flying and your flight instruction to others in a non-owned, fixed wing, non-pressurized, land aircraft having non-turbine single engine of 450 horsepower or less (including non-powered sailplanes) and a capacity of no more than seven (7) total passengers and/or seats and having standard airworthiness certificate. 1. Pilot Information:  Your Name:  FORMTEXT       Your Pilot Certificate:  FORMCHECKBOX Student  FORMCHECKBOX Recreational  FORMCHECKBOX Private  FORMCHECKBOX Commercial  FORMCHECKBOX ATP Address:  FORMTEXT       Your Ratings:  FORMCHECKBOX Instrument  FORMCHECKBOX  Other: FORMTEXT       City:  FORMTEXT      , State:  FORMTEXT    Zip:  FORMTEXT       Total Logged Hours:  FORMTEXT       Total Logged hours last 12 months:  FORMTEXT       What type of aircraft do you usually fly?  FORMTEXT       Your Occupation:  FORMTEXT       Your hours as PIC in type:  FORMTEXT       Your Age:  FORMTEXT       Do you have a CFI-Instrument?  FORMDROPDOWN  CFI-Multi-Engine?  FORMDROPDOWN  Hours flight instructing:  FORMTEXT       Flight instruction given last 12 months:  FORMTEXT       Within the last 36 months have you: 1. Been involved in any aircraft accident/incident?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Been cited for any FAR violation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. had your pilots or drivers license suspended?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. been convicted of any felony or DUI charge?  FORMCHECKBOX  Yes  FORMCHECKBOX  No *If you answered yes to any of the above, please contact your insurance agent before completing the application. 2. Coverages: Liability Coverage: Pays for bodily injury and property damage for which you are legally liable arising out of your use of non-owned aircraft but excluding physical damage to non-owned aircraft. Personal RenterEach OccurrencePassengersPremium$250,000$25,000$95  FORMCHECKBOX $500,000$50,000$115  FORMCHECKBOX $500,000$100,000$180  FORMCHECKBOX $1,000,000$100,000$240  FORMCHECKBOX  Flight InstructorsEach OccurrencePassengersPremium$250,000$25,000$200  FORMCHECKBOX $500,000$50,000$350  FORMCHECKBOX $500,000$100,000$500  FORMCHECKBOX $1,000,000$100,000$650  FORMCHECKBOX  Physical Damage to Your Non-Owned Aircraft: Pays for physical damage to non-owned aircraft for which you are legally liable. This coverage is only available in conjunction with Liability Coverage. Physical Damage LimitPremiumPhysical Damage LimitPremium$5,000$125  FORMCHECKBOX $60,000$600  FORMCHECKBOX $10,000$175  FORMCHECKBOX $80,000$775  FORMCHECKBOX $20,000$250  FORMCHECKBOX $100,000$975  FORMCHECKBOX $40,000$450  FORMCHECKBOX $150,000$1,425  FORMCHECKBOX Decline Physical Damage Coverage  FORMCHECKBOX  Optional Coverage: Add my employer as an additional insured $50*  FORMCHECKBOX  Name of Employer  FORMTEXT       * Your employer may require this coverage if you use non-owned aircraft on company business. This coverage is not available to Student or Recreational pilots. Coverage does not apply to employers who are: involved in the manufacture, building, designing, selling, or distribution of aircraft, aircraft engines, parts, accessories, components, or fuel; engaged in the operation of an aircraft repair shop, sales agency, rental service, flight school, pilot training center or any other commercial flying service. Add the Civil Air Patrol Endorsement $50** FORMCHECKBOX  ** This coverage may be purchased to protect you against claims arising from your participation in Civil Air Patrol Activities. Contact your broker for more information. 3. I would like to begin coverage on  FORMTEXT       for one year. I understand that coverage shall not be effective until the company has accepted by application and premium payment has been received in full through a producer appointed by AIG Aviation. I also understand that my actual policy will have terms and conditions not found in this general description. I warrant that all of the information in this application is true and complete to the best of my knowledge. I have enclosed a check payable to my agent in the amount of $ FORMTEXT       (Certain state taxes may apply please contact your agent regarding any state taxes applicable for your state.) I understand that once coverage is bound, a minimum of 50% of the premium is fully earned. Your Signature: ____________________________ Todays Date __________________ Your Phone ____________________________ *Some states require that we notify you that any person who knowingly and with intent to defraud any insurer, or other person, files an insurance application containing false or misleading information or any fact material thereto, commits a fraudulent insurance act which is a crime. Producer: National Aviation Insurance Agency, Inc. 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