Name of Applicant(s)

Applicant's Address:

City:   State:   Zip:

Home Ph#:     Work Ph#:      Fax Ph#:

Email Address:

Business or Occupation of Applicant:

Coverage Effective from:     Until: 12:01 Standard Time at above address

Applicant is:   Individuals    Partnership    Corporation   Holding Company   Government

Other (describe): and is owned,
controlled, or a subsidiary of:

Is Applicant incorporated solely for ownership of the aircraft below?   No     Yes

LIABILITY COVERAGE

AIRCRAFT

If Airworthiness Certificate is other than Standard or Normal, please indicate category:

Describe any STC's and Modifications

Year/Make/Model N#    

Registration Number:         

Total Seats Crew:  Total Seats Passenger:

Craft 1:   Land  Sea   Amphibian   Roto-wing

    Purchased New   Date      Purchased Used    Date

Craft 2:   Land  Sea   Amphibian   Roto-wing

    Purchased New   Date      Purchased Used    Date

Craft 3:   Land  Sea   Amphibian   Roto-wing

    Purchased New   Date      Purchased Used    Date

Price Paid (including extras)      

Present Estimated Value (including extras)      

Engine Hrs. since new, or since last major overhaul:       

Engine Make and horsepower: 

Aircraft Usually Based at: Name/City/State: 

Craft 1: Click Here --> hangared tied

Craft 2: Click Here --> hangared tied

Craft 3: Click Here --> hangared tied

Does Applicant hangar, service, repair or crew other aircraft? No  Yes

If yes please describe:

Are any unapproved airports or unpaved runways used? No  Yes

If yes please describe:

Is any aircraft registered under other names than Applicant's name above? No  Yes

If yes please describe:

Describe all navigation outside the USA & Canada:

List all partners and owned, controlled, affiliated and subsidiary firms on separate sheet:

List Attached Please email the above information to:  info@firsttower.com

PURPOSE OF USE

CHECK ALL APPLICABLE USES

Pleasure or Business (not flown by professional pilots employed for this purpose)

             Instruction   Rental (Commercial)

Corporate-Executive (flown only by professional pilots employed for his purpose)

            Flying Club   Photography

Passenger Carrying for Hire

(Charter/Air Taxi)   Air Ambulance (Charter/Air Taxi)   Freight Carrying (Charter/Air Taxi)

            Pipeline/Powerline Patrol   Banner Towing   Crop Dusting

List all other uses not indicated above (explain)

Pilot Qualifications#1:

Name:       Age:  

Pilot Certificates and Ratings:

Student   PVT   CML    AMEL   Instrum.   AIP         Other:

Medical Certificate:      Expiration Date    Class

Logged Pilot in Command Hours:

Date of last B.F.R.   Total Time    Total R/G    Total M/E

Total Tail Wheel       Other  

Total Hours in Aircraft Model to be Insured: 

Total Hours in All Aircraft Past 90 Days:       12 Months

Pilot Qualifications#2:

Name:       Age:  

Pilot Certificates and Ratings:

Student   PVT   CML    AMEL   Instrum.   AIP         Other:

Medical Certificate:      Expiration Date    Class

Logged Pilot in Command Hours:

Date of last B.F.R.   Total Time    Total R/G    Total M/E

Total Tail Wheel       Other  

Total Hours in Aircraft Model to be Insured: 

Total Hours in All Aircraft Past 90 Days:       12 Months

Pilot Qualifications#3:

Name:       Age:  

Pilot Certificates and Ratings:

Student   PVT   CML    AMEL   Instrum.   AIP         Other:

Medical Certificate:      Expiration Date    Class

Logged Pilot in Command Hours:

Date of last B.F.R.   Total Time    Total R/G    Total M/E

Total Tail Wheel       Other  

Total Hours in Aircraft Model to be Insured: 

Total Hours in All Aircraft Past 90 Days:       12 Months

Do any pilots named above have any: (a) physical impairments? 

(b) waivers, limitations, conditions attached to their medical certificates?

Has an FAA or Military Pilot Certificate held by any pilot named above ever been suspended or revoked?

if so explain:

Has any Pilot named above ever been cited for any violation of Federal Air Regulations?

If so explain: 

Has any pilot named above ever been involved in any aircraft accident?

If so explain: 

Has any applicant, or officer of partner thereof, or pilot above ever been indicted for or been arrested for a felony,
drunk or reckless driving? If so explain: 

Has any applicant, or officer or partner thereof, or pilot been convicted in or indicted in a legal

action involving drugs? 

Applicant is: Sole owner of the aircraft    Owner subject to mortgage or conditional sales contract

Other - explain:

If aircraft is mortgaged, name and address of mortgagee: 

Amount of mortgage (excluding interest and finance charges: $

Will Breach of Warranty Coverage be required by mortgagee? No   Yes

Are any other Aircraft or helicopters owned by, rented or used by or on behalf of Applicant?  No   Yes

Model Aircraft/helicopter   Uses   

Number of hrs./year 

Name of last (Current) Aircraft insurance carrier (if none so state): 

Current Policy Number:

To the Insured's knowledge no damage has been sustained to,  nor claims by others have arisen out of
the operation of any aircraft owned by or in the custody of the insured except:

Has any Insurance Company or Underwriter at any time declined an aircraft application submitted by or
cancelled or refused to renew an aircraft policy held by the applicant or any of the pilots named herein?

Yes   No     If so, explain: