SIMPLIFLY Starr NOP Application | Advantage Aviation Insurance

POLICY PERIOD. Insurance coverage is requested to begin 12:01 AM on date listed.*

Full Name*

Age*

Your email*

Contact Phone*

Street Address*

City*

State*

Zip Code*

Business or Occupation

Non-Owned Aircraft You Usually Operate*

Hours Flown Last 12 Months*

Medical & BFR / As of the date of this application is your medical and BFR current as required by FAR 61.56*

Yes

PILOT EXPERIENCE / Total Logged Hours*

PILOT EXPERIENCE / Conventional Gear or Tailwheel*

PILOT EXPERIENCE / Retractable Gear (if applicable)

PILOT EXPERIENCE / Multi-Engine (if applicable)

PILOT EXPERIENCE / Rotowing

In the past 36 months have you been involved in an aircraft accident or incident?*

Yes

In the past 36 months have you had an FAA violation?*

Yes

In the past 36 months have you been convicted of a DUI or crime classified as a felony?*

Yes

In the past 36 months have you been cancelled or declined or refused an aircraft insurance policy?*

Yes

For any response above marked "Yes" please provide an explanation - may be subject to additional underwriting.

I would like coverage for the following types of non-owned aircraft:*

SINGLE ENGINE: Fixed wing non-pressurized land aircraft (including sailplanes/glider) having a single piston engine not exceeding 450 rated horsepower and no more than 7 total seats.

MULTI-ENGINE: Fixed wing non-pressurized land aircraft (including sailplanes/glider) having a single piston engine not exceeding 450 rated horsepower and no more than 7 total seats and including a fixed wing non-pressurized multi-engine piston powered land aircraft having no more than 350 rated horsepower (each engine) and no more than 7 total seats.

ROTOCRAFT: Fixed wing non-pressurized land aircraft (including sailplanes/glider) having a single piston engine not exceeding 450 rated horsepower and no more than 7 total seats and including rotor-wing aircraft having a single piston powered engine not exceeding 450 rated horsepower and no more than 4 total seats.

I REQUEST AND AGREE TO THE FOLLOWING COVERAGE OPTION: Non-Owned Injury and Property Damage Excluding Loss of Use of Non-Owned Aircraft for $250,000 each occurrence limiting passenger bodily injury to $25,000 each person.*

YES

I REQUEST AND AGREE TO THE FOLLOWING COVERAGE OPTION: Medical limit of $1,000 each person.*

YES

I REQUEST AND AGREE TO THE FOLLOWING COVERAGE OPTION: Non-Owned Physical Damage Liability Including Loss of Use of Non-Owned Aircraft at $50,000 each occurrence.*

YES

NOTICE TO APPLICANTS:

NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS:

NOTICE TO CALIFORNIA APPLICANTS:

NOTICE TO COLORADO APPLICANTS:

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:

NOTICE TO FLORIDA APPLICANTS

NOTICE TO HAWAII APPLICANTS:

NOTICE TO KENTUCKY APPLICANTS:

NOTICE TO LOUISIANA APPLICANTS:

NOTICE TO MAINE APPLICANTS:

NOTICE TO MARYLAND APPLICANTS:

NOTICE TO MINNESOTA APPLICANTS:

NOTICE TO NEW JERSEY APPLICANTS:

NOTICE TO NEW YORK APPLICANTS:

NOTICE TO OHIO APPLICANTS:

NOTICE TO OKLAHOMA APPLICANTS

NOTICE TO OREGON APPLICANTS:

NOTICE TO PENNSYLVANIA APPLICANTS:

NOTICE TO RHODE ISLAND APPLICANTS:

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS:

NOTICE TO TEXAS APPLICANTS:

NOTICE TO UTAH APPLICANTS:

NOTICE TO ALL OTHER APPLICANTS:

SIGNATURE: By typing your name in the field below, you acknowledge that this electronic signature represents your intent to sign and authorize this transaction. Your typed name is legally binding and carries the same effect as a handwritten signature.*

DATE:*

Application for Personal Non-Owned Aircraft Insurance

If you are using non-owned aircraft for other than your non-commercial pleasure and business use, please contact your aviation insurance broker/representative.

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