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    • Format: (000) 000-0000.
    • Policy Expiry Date (if you currently have insurance):
       - -
      2 digit month, 2 digit day, 4 digit year
    • Desired Effective Date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Aircraft Information
      Rows
    • LOSS PAYEES, LIEN HOLDERS, & ADDITIONAL INSURED
    • PURPOSE OF USE
    • Will aircraft be used on other than paved runways?*
    • Does Applicant own or exclusively lease any other aircraft?*
    • Does Applicant have any Non-Owned Aircraft exposure?*
    • Will anyone other than named pilots operate the insured aircraft?*
    • Will insured aircraft be used outside the continental United States?*
    • Will insured aircraft be used for anything other than transporting passengers?*
    • Has Applicant or Named Pilot(s) ever had any incidents, accidents, claims, or violations?*
    • Has Applicant or Named Pilot(s) ever had any felony convictions or license suspensions?*
    • Has Applicant ever had insurance denied or cancelled?*

    • Emergency Contact

    • Format: (000) 000-0000.
    • Aviation Memberships
      Rows

    • Any person who knowingly and willfully presents false information in an application for insurance may be guilty of insurance fraud and subject to fines and confinement in prison. (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties).

    • THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED.

    • Date*
       - -
      2 digit month, 2 digit day, 4 digit year

    • Producer: Jerry Clemens
      Clemens Insurance Agency
      401 N 16th Parsons, KS 67357
      National Producer Code: 2939938
      Email: jerry@clemensinsurance.net

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