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Special Notes
On-line quotations are not available to Kentucky residents due to state tax requirements. Please call toll free (888) 241-7891 for assistance. IMPORTANT, YOU MUST BE OF LEGAL AGE IN YOUR STATE TO ENTER INTO A CONTRACT.

The Avemco Non-Owned Aircraft Insurance Policy is available for U.S. registered aircraft that are fixed-wing, land based & have a Standard Airworthiness Certificate, or be certified in the Special Light Sport Category. The aircraft also may not have more than 7 seats, an engine with more than 450 HP, or a turbine engine.

For a non-owned aircraft policy, all policyholders must be individuals not a business. You have the option of adding your employer as an additional insured. However, if your employer is engaged in an aviation business please call (888) 241-7891 for information on obtaining coverage.

First Name:* M.I.:*	Last Name:*
Address:*	City:*
State:* AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MH MP PR PW VI	Zip:*
Date of Birth (mm/dd/yy):*	Day Phone:*
Evening Phone:	Fax:
Email:*	Occupation:
Contact Preference: Email Phone Mail Fax	How did you hear about us?* Select One FBO Referred CFI Referred Friend Referred Past Avemco Customer Current Avemco Customer Magazine Ad Received Mailing Link from Other Website Other
Name of Referring FBO/CFI:
Renting for Commercial Purposes?* YesNo	Employer as additional insured?* YesNo
Employer Name:
Address #1:	Address #2:
City:	State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MH MP PR PW VI Zip:

Coverage Desired *

Standard Non-Owned Standard Non-Owned Multi-Engine Standard Non-Owned & CFI Standard Non-Owned Multi-engine & CFI Standard Light Sport Non-Owned

Additional Information

Practical Risk Management Course Completion Code: (completion code contains numbers and letters and is case sensitive)

Add'l certificates, ratings or recurrent training in last 12 months:

YesNo

*If Yes, detailed information required including type & amount of hours below:

Section 2 - Pilot Information

FAA Certificate # (optional):	FAA Certificate Type:* Student Private Commercial ATP Sport Pilot Recreational
Total Flight Time:	Total time in last 12 months:
Instrument Rating:* YesNo	Current FAA Flight Review:* YesNo
Pre-solo Student:* YesNo	Coverage Exclusively to Fly Gliders:* YesNo
Valid Medical for FAA Certificate:* YesNo
(Note: Glider and Pre-solo Student Pilots do not require a medical certificate to obtain insurance.)
Within the past 36 months have you:
*Been cancelled, declined, or refused renewal on an aircraft insurance policy? (Does not apply in Missouri)	YesNo
*Had an aircraft accident, incident, or insurance claim?	YesNo
*Had your pilot's or driver's license surrendered, suspended, or revoked?	YesYes
*Been arrested or charged with operating an aircraft or motor vehicle while under the influence of drugs or alcohol?	YesNo
*Been convicted of, or pleaded "guilty" or "no contest" to any felony or misdemeanor other than parking violations?	YesNo
If YES to any of the above 5 questions please explain below:

Section 3 - Coverage Options

*Bodily Injury and Property Damage Liability Limits & Annual Rates

Select One Each Person Property Damage Each Accident Premium $25,000 $250,000 $250,000 (need amount to auto-fill) $50,000 $500,000 $500,000 (need amount to auto-fill) $100,000 $500,000 $500,000 (need amount to auto-fill) $100,000 $1,000,000 $1,000,000 (need amount to auto-fill)

Aircraft Damage Liability (Optional)

Select One Limit Premium $1,000 (need amount to auto-fill) $5,000 (need amount to auto-fill) $10,000 (need amount to auto-fill) $15,000 (need amount to auto-fill) $25,000 (need amount to auto-fill) $35,000 (need amount to auto-fill) $50,000 (need amount to auto-fill) $75,000 (need amount to auto-fill) $100,000 (need amount to auto-fill) $150,000 (need amount to auto-fill)