United States Association of Flying Clubs Member Insurance Application

Club Name
Contact Name
Street
City State Zip
Telephone Fax Email
Airport Years in Business
Club Occupies : sf Office Hangar(s) # of Tiedowns
Present Insurance Company Expires

Has any insurer canceled, declined or refused to renew any aviation insurance YES NO

If yes, why?

Total Premiums Paid Past 5 years
$ $ $ $ $

 

Aircraft Losses Past 5 years
Date Liability Claim Paid $ Hull Claim Paid $
Description of Loss
Date Liability Claim Paid $ Hull Claim Paid $
Description of Loss
Date Liability Claim Paid $ Hull Claim Paid $
Description of Loss
Date Liability Claim Paid $ Hull Claim Paid $
Description of Loss

If more than 4 Losses use email to describe them

 

Aircraft Schedule
 
FAA N#
Year
Make and Model
Insured Value
1 $
2 $
3 $
4 $
5 $
6 $
7 $
8 $
9 $
10 $
11 $
12 $
13 $
14 $
15 $
16 $
17 $
18 $
19 $
20 $
21 $
22 $
23 $
24 $
25 $
26 $
27 $
28 $
29 $
30 $
  Notes
   

 

Southwest Aviation Insurance Group
Mark Nichols
 
Dave Monaco
14415 N. 73rd Street, Suite 115
Scottsdale, AZ 85260
800-324-6787

 

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