Heffernan Insurance Brokers
Aviation Insurance Request Form
Please complete the form below, and one of our team members will reach out to discuss your aviation insurance needs.
Date
Policyholder's Name*
Address
Name of Person to Contact
Are you a member of the Soaring Society of America? Yes No
If yes, please provide your SSA membership #
Occupation/Nature of business
Are you a member of the Aircraft Owners and Pilots Association (AOPA) Yes No
If yes, please provide your AOPA membership#
Are you just purchasing this aircraft? Yes No
If no, please Provide the Name of Your Present Insurance Company (not agent)
Policy expiration date
Aircraft Schedule
Pilot 1
Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG)
Total Glider Flights
Total flights in glider with a glide ratio of 35-1 or better
Total Flights in each Make & Model to be Insured
Any physical disabilities that might impact the pilots ability to operate the glider? Yes No
If yes, please describe:
Pilot 2
Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG)
Total Glider Flights
Total flights in glider with a glide ratio of 35-1 or better
Total Flights in each Make & Model to be Insured
Any physical disabilities that might impact the pilots ability to operate the glider? Yes No
If yes, please describe:
Pilot 3
Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG)
Total Glider Flights
Total flights in glider with a glide ratio of 35-1 or better
Total Flights in each Make & Model to be Insured
Any physical disabilities that might impact the pilots ability to operate the glider? Yes No
If yes, please describe:
For all pilots, please list any aviation accidents, waivers, violations, losses, incidents, DUI or DWI’s below: Give dates and details. If none, say none in the box below.
Comments
Thank you for taking the time to complete this form.
