Welcome!

Please complete the following Insurance Request form a minimum of 30 days prior to the event. The form is not required for normal monthly meetings.

Once the form is submitted, you have the opportunity to print a copy for your records. After the request has been reviewed and approved, you will receive a confirmation e-mail and certificate of insurance.

If the Risk Management Office requires additional information they will contact you directly prior to the event being processed and approved.

If you have any questions or we can be of help in any way, please contact Risk Management at: 920-426-6106, (800) 236-4800 Ext. 6106 (M-F 8:15am – 5:00pm) or chapterinsurance@eaa.org.

EAA Event Insurance Request Form. Bold fields are required:
Your Name:
Your EAA Number:
Your Phone Number:
Emergency Cell Number:
Your Email Address:
Your EAA Chapter:	Find Your Chapter!
Event Name:
Event Start Date:	(mm/dd/yyyy)
Event End Date:	(mm/dd/yyyy)
Recurring Event?	YesNo
Describe when this event recurs. Note: All aspects of the event must remain the same. (300 characters max)
Number of set-up days:	none 1 2 3 4 5 6 7 8 9 10
Number of tear-down days:	none 1 2 3 4 5 6 7 8 9 10
Rain Start Date:	(mm/dd/yyyy)
Rain End Date:	(mm/dd/yyyy)
Event Airport ID:	Airport Lookup (US & Canada only)
Facility Name:
Street Address 1:
Street Address 2:
City:
State/Province:	------------ Alabama, US Alaska, US Arizona, US Arkansas, US California, US Colorado, US Connecticut, US Delaware, US District of Columbia, US Florida, US Georgia, US Hawaii, US Idaho, US Illinois, US Indiana, US Iowa, US Kansas, US Kentucky, US Louisiana, US Maine, US Maryland, US Massachusetts, US Michigan, US Minnesota, US Mississippi, US Missouri, US Montana, US Nebraska, US Nevada, US New Hampshire, US New Jersey, US New Mexico, US New York, US North Carolina, US North Dakota, US Ohio, US Oklahoma, US Oregon, US Pennsylvania, US Rhode Island, US South Carolina, US South Dakota, US Tennessee, US Texas, US Utah, US Vermont, US Virginia, US Washington, US West Virginia, US Wisconsin, US Wyoming, US Alberta, Canada British Columbia, Canada Manitoba, Canada New Brunswick, Canada Newfoundland and Labrador, Canada Nova Scotia, Canada Northwest Territories, Canada Nunavut, Canada Ontario, Canada Prince Edward Island, Canada Québec, Canada Saskatchewan, Canada Yukon, Canada
Your Chapters role in this Event	Sole Organization Chapter is the only organization involved in the planning and conduct of the event. Co-Sponsor Chapter is one of the organizations planning and conducting the event. Participant Chapter will provide an activity (i.e. breakfast, lunch, Young Eagles, Chapter display) at an event that the Chapter/ is not the sole organizer or co-sponsor of. Other Please describe in detail, including careful clarification of Chapter’s role in planning, meetings, revenue, and promotion. Provide any pertinent additional information If Other, please describe: (300 characters max)
Are you the primary sponsor?	YesNo
Who is the primary sponsor? What will they provide at the event (role/activities)? (300 characters max)
Is any person or organization requesting additional insured status under this insurance?	Yes No
Please list any person or organization requesting additional insured status under this insurance: Name: Name: Address: Address: City, State Zip: City, State Zip: Role*: Role*:                    * (Role in the event (ex. owner of airport, FBO providing use of hangar space, etc.) List all items or products that the above additional insured will sell at this event. Items/Products: (150 characters max) Items/Products: (150 characters max)
Will the chapter sign any contracts, leases or other agreements related to this event?	Yes No
Please list all contracts/leases/agreements that the Chapter has or will sign for this event. Contracts, Leases or Agreements: (300 characters max)
Will any vendors or exhibitors be participating in this event?	YesNo
Number of Vendors/Exhibitors participating in your event: none 1 2 3 4 5 6 7 8 9 10 > 10 Fee per Vendor/Exhibitor:
Estimate of Attendance:
EAA Members:
General Public:
THE FOLLOWING ACTIVITIES ARE NOT COVERED BY THIS INSURANCE AND ARE NOT PERMITTED AT ANY EAA FLY-IN EVENT.
> Aerobatics - Paid or Unpaid(Does not include IAC contests) > Parachute Jumpers > Airshow requiring Waivered Airspace > Pyrotechnics/Fireworks > Anything with respect to waivered airspace > Racing of any kind > Balloon Breaking > Ribbon Cutting > Endurance Flights Involving Fuel Exhaustion > Sale of Alcoholic Beverages > Flour Bombing > Simulated Aerial Combat > Night Airshows > Wing Walking
Please check all activities your chapter is responsible for at the event:
Adult Orientation Rides from Chapter Members - fee charged Formation Flights Adult Orientation Rides from Chapter Members - no fee Hot Air Balloons Aircraft Manufacturer Demonstration Rides IAC Aerobatic Contest - IAC Chapters only Aircraft Static Displays IAC Chapter Practice Day-IAC Chapters only Aviation Exhibitors Non-Aviation Exhibitors Awards Banquet Pancake Breakfast Car, Motorcycle, Farm Equipment Display Poker Run Event Cook-out Radio Controlled Aircraft Demonstrations Demonstrations Ride/Hopping/Site Rides - Commercial Rules Fly-bys (showcase-parade of flight) Spot Landing Contest Fly-In Ultralight Pilot Proficiency Events Fly-Market/Parts Mart Warbird Fly-bys Fly-Out Workshops Food Vendors Young Eagle Rides  Other:
Will the chapter be using any ground vehicles (e.g. golf carts, scooters, cars, trucks, etc.) to support the event?	Yes No
Input the number of vehicles by type and how they will be used during the event: (Please provide a certificate of insurance on each vehicle.) Automobiles (cars and trucks) Buses Tractors and wagons Golf carts, gators, motorcycles, scooters, ATVs, etc Other Use:
The space below may be used should you wish to include any additional information. (1000 characters max)
By selecting "Yes" below the submitter declares that to the best of his/her knowledge and belief that the statements set forth herein are true and that they have been authorized by the Chapter to request insurance for this event. Please be advised, incomplete or inaccurate information may impair insurance coverage. This application does not commit the insurers or EAA to any liability until the company agrees to effect this insurance.
Yes