EAA Aircraft Insurance Plan Application (US)

Please complete this online quote request for aircraft insurance. When you are finished, please click the “Continue” button. If you have an EAA.org account, logging in will auto-fill portions of this form.

Bold fields are required

Personal Information

Contact First Name:

Contact Middle Name:

Contact Last Name:

Name Insured:

Address 1:

Address 2:

City:

State/Province:

Postal/Zip Code:

Contact Phone:

Email Address:

One phone number is required

Home#:

Work#:

Cell#:

Membership Numbers

EAA Member #:

Additional discounts or benefits may be available to members of the following organizations

Vintage Aircraft Association #:

International Aerobatic Club #:

Warbirds of America #:

Aircraft Owners & Pilots Association #:

Antique Aircraft Association #:

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Your list of Aircraft

Year	Make	Model
			Edit	Delete

Add Aircraft

Aircraft Information

Aircraft Use:

(If commercial use, explain here)

(Other use, explain here)

Aircraft FAA "N" Number: Aircraft "C" Number:

Unknown

(If unknown, please explain)

Aircraft Year:

Aircraft Make:

Aircraft Model:

Gear Configuration:

Total Seats:

Number of PASSENGER Seats:

Engine Make:

Horsepower:

Hours Since Last Overhaul

Coverage Requested

Aircraft Hull Value:

Landplane Value:

SeaPlaneValue:

Amphibian Value:

Ski Value:

Aircraft Hull Insurance:

Limits of Liability Insurance:

Limits of Liability Insurance (please check one coverage limit per section):

Medical Payments Insurance:

Insurance Information Request

Quote For:

Current Policy Expire Date:

Current Insurer:

Please complete the following fields if "Work in Progress" is selected above

Current Value:

Completed Value:

Serial, Kit or Builder #:

Current Project Location Address:

Airport Information

Airport Name:

Aircraft Status:

Airport Identifier

Runway Length:

Runway Surface:

Elevation:

City:

State/Province:

Lien Holder

There will be a lien on the aircraft:

Lien Holder Name:

Address 1:

Address 2:

City:

State/Province:

Postal/Zip Code:

Fax:

Lien Amount:

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Your list of Pilots

First Name	Last Name
		Edit	Delete

Add Pilot

Pilot Information

Pilot First Name:

Pilot Middle Name:

Pilot Last Name:

Occupation:

Date of Birth:

Age:

Certificate:

License:

Ratings:

Have you had any of the following in the last 5 years?

Additional information:
(convictions, surrender, revocation, accidents, incidents, claims, citations, violations, or suspensions)

Aircraft:

Check all aircraft this pilot will fly

Total Flight Hours for

Total Flight Hours Logged in Last 12 Months

Total Lifetime Flight Hours

Other Hours:

*Hours Above Are Required

Seaplane

Amphibian

WSC

PPC

Glider

Gyro

Skiplane

(RG=Retractable ME=Multi-Engine TW=Tailwheel RW=Rotorwing)

Last BFR Date:

Sport Pilot:

Basic Medical:

Sport Pilot:

Basic Medical:

You have a current medical:

If no current medical, please explain
(e.g. BasicMed)

Medical Date:

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What communication prompted you to submit this application (check all that apply)

If "Other" explain:

Before you submit your quote request, do you have any additional questions or comments for us?

Questions/Comments:

Claims/Violations:

Claims/Violations Explanation:

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Summary

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EAA Aircraft Insurance Plan Application (US)

Personal Information

Membership Numbers

Your list of Aircraft

Aircraft Information

Coverage Requested

Insurance Information Request

Airport Information

Lien Holder

Your list of Pilots

Pilot Information

Summary