Application – EAA Aviation Insurance

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Leftseat Producer ID

Insured Information

EAA Membership # (Optional)

First Name

Last Name

Address

City

State

Zip Code

Email

Phone

Insured is a Pilot?

Insured is a pilot

When checked, this information will auto-populate Pilot 1’s basic information.

How many aircraft will be on the policy?

1

2

3+

Aircraft 1 Tail Number

I don’t know

Aircraft 2 Tail Number

I don’t know

Owner Type

Owner's Name

How many pilots regularly fly the aircraft on the policy?

1

2

3

4

5+

Pilot 1

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First Name

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Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

Date of Birth

Month

Day

Year

Pilot 2

First Name

Last Name

Date of Birth

Month

Day

Year

Pilot 3

First Name

Last Name

Date of Birth

Month

Day

Year

Pilot 4

First Name

Last Name

Date of Birth

Month

Day

Year

Aircraft Information

✈️ Aircraft 1

Year

Make

Model

Additional Details

Include Hull Coverage

Include Hull Coverage

Base Hull Value ($)

Hull Value with Floats ($)

Hull Value with Skis ($)

Landing Gear

Additional Equipment or Modifications

Aircraft Storage

Airport Code

Under Construction

Total Seats

Usage

Ownership Interest

Select which pilots have an ownership interest in this aircraft:

✈️ Aircraft 2

Year

Make

Model

Additional Details

Include Hull Coverage (Aircraft 2)

Include Hull Coverage

Base Hull Value ($)

Hull Value with Floats ($)

Hull Value with Skis ($)

Landing Gear

Additional Equipment or Modifications

Aircraft Storage

Airport Code

Under Construction

Total Seats

Usage

Ownership Interest

Select which pilots have an ownership interest in this aircraft:

How many hours in the make and model aircraft to be insured?
Enter each pilots flight hours in this aircraft.

Pilot Information

👨‍✈️ Pilot 1

First Name

Last Name

Date of Birth

MM slash DD slash YYYY

State of Residence

Pilot Qualifications

License Type

Multi-Engine Rated

Instrument Rated

Medical Class

Additional Ratings

Additional Ratings

CFI (Certified Flight Instructor)

Sea Plane

Rotor Wing

Gyroplane

WSC/PTC

Memberships

Memberships

AOPA Member

AOPA Membership #

Flight Experience

Total Flight Hours

Flight Hours Last 12 Months

How many hours in the make and model aircraft to be insured?

(Total)

Hours

(Last 12 Months)

Hours

Retractable Gear Hours

Hours

Complex Aircraft Hours

Hours

Tailwheel Hours

Hours

Seaplane Hours

Hours

Ski-Equipped Hours

Hours

Multiengine Hours

Hours

👨‍✈️ Pilot 2

First Name

Last Name

Date of Birth

MM slash DD slash YYYY

State of Residence

Pilot Qualifications

License Type

Multi-Engine Rated

Instrument Rated

Medical Class

Additional Ratings

Additional Ratings

CFI (Certified Flight Instructor)

Sea Plane

Rotor Wing

Gyroplane

WSC/PTC

Memberships

Memberships

AOPA Member

AOPA Membership #

Flight Experience

Total Flight Hours

Flight Hours Last 12 Months

How many hours in the make and model aircraft to be insured?

(Total)

Hours

(Last 12 Months)

Hours

Retractable Gear Hours

Hours

Complex Aircraft Hours

Hours

Tailwheel Hours

Hours

Seaplane Hours

Hours

Ski-Equipped Hours

Hours

Multiengine Hours

Hours

👨‍✈️ Pilot 3

First Name

Last Name

Date of Birth

MM slash DD slash YYYY

State of Residence

Pilot Qualifications

License Type

Multi-Engine Rated

Instrument Rated

Medical Class

Additional Ratings

Additional Ratings

CFI (Certified Flight Instructor)

Sea Plane

Rotor Wing

Gyroplane

WSC/PTC

Memberships

Memberships

AOPA Member

AOPA Membership #

Flight Experience

Total Flight Hours

Flight Hours Last 12 Months

How many hours in the make and model aircraft to be insured?

(Total)

Hours

(Last 12 Months)

Hours

Retractable Gear Hours

Hours

Complex Aircraft Hours

Hours

Tailwheel Hours

Hours

Seaplane Hours

Hours

Ski-Equipped Hours

Hours

Multiengine Hours

Hours

👨‍✈️ Pilot 4

First Name

Last Name

Date of Birth

MM slash DD slash YYYY

State of Residence

Pilot Qualifications

License Type

Multi-Engine Rated

Instrument Rated

Medical Class

Additional Ratings

Additional Ratings

CFI (Certified Flight Instructor)

Sea Plane

Rotor Wing

Gyroplane

WSC/PTC

Memberships

Memberships

AOPA Member

AOPA Membership #

Flight Experience

Total Flight Hours

Flight Hours Last 12 Months

How many hours in the make and model aircraft to be insured?

(Total)

Hours

(Last 12 Months)

Hours

Retractable Gear Hours

Hours

Complex Aircraft Hours

Hours

Tailwheel Hours

Hours

Seaplane Hours

Hours

Ski-Equipped Hours

Hours

Multiengine Hours

Hours

Additional Questions

Has any pilot been arrested for reckless driving or DUI/DWI?

Yes

No

Please provide information:

Has any pilot been convicted of a felony, including use, sales, transportation, or possession of illegal drugs?

Yes

No

Please provide information:

Has any pilot been the subject of an FAA enforcement action, or had their pilot's license suspended or revoked?

Yes

No

Please provide information:

Has any scheduled pilot been involved in any accident within the past five years?

Yes

No

Please provide information:

Do all scheduled aircraft have current airworthiness in effect?

Yes

No

Is there any unrepaired damage to scheduled aircraft?

Yes

No

Please provide information:

Has any insurer cancelled, declined, or refused to renew any aviation insurance for any scheduled pilot?

Yes

No

Please provide information:

Additional Comments

Is there anything else you'd like to tell us about your aircraft or pilots?

Optional: Include any special circumstances, additional equipment, operating procedures, or other details that might affect your coverage.

Review Your Information

Aircraft Information

Tail Number: {Tail:14}	Make: {Make:57}	Model: {Model:58}
Year: {Year:59}	Base Hull Value: {Base Hull Value ($):64}	Airport Code: {Airport Code:68}
Aircraft Storage: {Aircraft Storage:67}	Type: {Owner Type:62}	Owner Name: {Owner\’s Name:61}

Tail Number: {Tail:18}	Make: {Make:101}	Model: {Model:102}
Year: {Year:100}	Base Hull Value: {Base Hull Value ($):107}	Airport Code: {Airport Code:113}
Aircraft Storage: {Aircraft Storage:112}	Type: {Owner Type:103}	Owner Name: {Owner\’s Name:104}

Pilot Information

Name: {First Name:77} {Last Name:78}	Date of Birth: {Date of Birth:25}	State: {State of Residence:26}
License Type: {License Type:82}	Total Flight Hours: {Total Flight Hours:177}	Medical Class: {Medical Class:85}
Multi-Engine Rated: {Multi-Engine Rated:83}	Instrument Rated: {Instrument Rated:84}

Name: {First Name:180} {Last Name:181}	Date of Birth: {Date of Birth:182}	State: {State of Residence:271}
License Type: {License Type:185}	Total Flight Hours: {Total Flight Hours:194}	Medical Class: {Medical Class:188}
Multi-Engine Rated: {Multi-Engine Rated:186}	Instrument Rated: {Instrument Rated:187}

Name: {First Name:199} {Last Name:200}	Date of Birth: {Date of Birth:201}	State: {State of Residence:272}
License Type: {License Type:204}	Total Flight Hours: {Total Flight Hours:213}	Medical Class: {Medical Class:207}
Multi-Engine Rated: {Multi-Engine Rated:205}	Instrument Rated: {Instrument Rated:206}

Name: {First Name:217} {Last Name:218}	Date of Birth: {Date of Birth:219}	State: {State of Residence:220}
License Type: {License Type:222}	Total Flight Hours: {Total Flight Hours:231}	Medical Class: {Medical Class:225}
Multi-Engine Rated: {Multi-Engine Rated:223}	Instrument Rated: {Instrument Rated:224}

Additional Questions

Has any pilot been arrested for reckless driving or DUI/DWI?	{Has any pilot been arrested for reckless driving or DUI/DWI?:235}
Has any pilot been convicted of a felony, including use, sales, transportation, or possession of illegal drugs?	{Has any pilot been convicted of a felony, including use, sales, transportation, or possession of illegal drugs?:236}
Has any pilot been the subject of an FAA enforcement action, or had their pilot’s license suspended or revoked?	{Has any pilot been the subject of an FAA enforcement action, or had their pilot’s license suspended or revoked?:237}
Has any scheduled pilot been involved in any accident within the past five years?	{Has any scheduled pilot been involved in any accident within the past five years?:238}
Do all scheduled aircraft have current airworthiness in effect?	{Do all scheduled aircraft have current airworthiness in effect?:239}
Is there any unrepaired damage to scheduled aircraft?	{Is there any unrepaired damage to scheduled aircraft?:344}
Has any insurer cancelled, declined, or refused to renew any aviation insurance for any scheduled pilot?	{Has any insurer cancelled, declined, or refused to renew any aviation insurance for any scheduled pilot?:345}

Looks like you have a large team.

For policies with more than 4 pilots, we’ll need to create a custom solution for you.

First Name

Last Name

Email

Phone

Additional Details

Bigger fleet?

For policies with more than 2 aircraft, we’ll need to create a custom solution for you.

First Name

Last Name

Email

Phone

Additional Details

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