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Kel Petersen & Associates, Inc.
5738 N. Broadway Street
Kansas City, MO 64118
Phone:
(816) 421 5959
(800) 777 5960
Fax:
(816) 421 1489
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Request an Insurance Quote
Aircraft Insurance Quote
New purchase:
Yes
No
Name of Registered Owner:
Contact Name:
Occupation:
Phone:
Cell:
E-mail Address:
Number of Aircraft:
<-Select->
1
2
3
Aircraft 1
Hangared
Tied
Airport Identity:
Make and Model
FAA N # :
Year of Manufacture:
Total Seats:
Type of Aircraft:
<-Select->
Single Engine Land
Mulity Engine Land
Single Engine Sea
Multi Engine Sea
Rotorwing
Turbine prop
JET
Glider
Other
Gear Type:
<-Select->
Fixed Tri
Retract
Tail Wheel
Nosewheel
Aircraft Value $:
Liability Limit Per Occurrence:
<-Select->
$500,000
$1000000
$2000000
$3000000
$4000000
$5000000
Per Passenger:
<-Select->
$100,000
$150,000
$200,000
$250,000
Combined Single Limit
Comments:
Purpose of Use:
Pleasure and Business - The term pleasure and business is defined as personal and pleasure use and direct connection with the insured business excluding any operation for which a charge is made.
Industrial Aid - The term 'Industrial Aid' is defined as including all the uses enumerated in the definition of 'Pleasure and Business' and also includes transportation of executives, employees, guests and customers, excluding any operation for which a charge is made;
Limited Commercial - The term 'Limited Commercial' is defined as including all the uses permitted in (a) and (b) above and including Student Instruction and Rental to pilots but excluding passenger carrying for hire or reward;
Commercial Ex Instruction or Rental - The term 'Commercial Ex Instruction or Rental' is defined as including all the uses under (a) and (b) above and use of the aircraft for the transport of passengers and or freight for hire but excluding any use of aircraft for instruction or rental to others;
Commercial - The term 'Commercial' is defined as including all the uses under (c) and (d) above;
Flying Club - The term 'Flying Club' is defined as including all the uses permitted in (a) above;
Special Uses - The term 'Special Uses' is defined as;
Pilots Information
Number of Pilots:
<-Select->
1
2
3
4
5
Pilot 1:
Name of Pilot:
Date of Birth:
Type of Certificate:
<-Select->
Student
Sports/Rec.
Private
Commercial
Airline Transport Pilot
Rating:
<-Select->
IFR
CFI
CFII
RW
MEL
SEL
TW
SES
MES
MEI
Aircraft Type Rating:
Total Logged Hours:
Total Hours for this Make Model:
Total Hours Multi Engine:
Total Hours Retractable Gear:
Total Hours Tailwheel:
Total Hours Round Engine:
Total Hours Turbo Prop:
Total Hours Rotor Wing:
Total Hours Last 12 Mos:
Is pilot a Member of:
AOPA
EAA
Warbirds
Membership # :
AIRCRAFT/AIRCRAFT OPERATIONS SECTION
A. Does aircraft have other then a standard airworthiness certificate in full effect?
Yes
No
B. Are there any other aircraft owned by the Applicant?
Yes
No
C. Has aircraft been equipped with any modifications not provided by manufacturer?
Yes
No
D. Do you anticipate aircraft to be operated outside the continental United States?
Yes
No
E. Will aircraft be normally operated from other than paved public airports?
Yes
No
F. Will aircraft be used for student or pilot instructions other than for recurrent training of pilots listed in Pilot?
Yes
No
G. Will other than the Applicant and pilots listed in Pilots on reverse have use of aircraft?
Yes
No
H. Will aircraft be used for any purpose(s) for which a charge is made?
Yes
No
I. Is there any unrepaired damage to aircraft?
Yes
No
J. Has Applicant had any aircraft/aviation losses or claims in last 10 years?
Yes
No
K. Do any pilots named have any physical impairments, waivers or statement of demonstrated ability (other than for corrective lenses) limitations or conditions attached to their medical certificate?
Yes
No
L. Have any pilots named had any convictions, suspensions, or revocations for, FAR violations, use or possession of drugs, or reckless or drunk driving?
Yes
No
M. Has any pilot named ever been involved in any accident or incident?
Yes
No
N. Has any pilot named ever been convicted of a felony?
Yes
No
Please explain any 'Yes' answer in the space below referring to section & item (above):
No coverage of any kind is bound or implied by submitting information via this online form.
We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.
Yes, I Agree.
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