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?
YesNo

If yes, please provide your SSA membership #

Occupation/Nature of business

Are you a member of the Aircraft Owners and Pilots Association (AOPA)
YesNo

If yes, please provide your AOPA membership#

Are you just purchasing this aircraft?
YesNo

If no, please Provide the Name of Your Present Insurance Company (not agent)

Policy expiration date

Aircraft Schedule

FAA N#	Year Make & Model	Glider Value	Trailer Value
1.
2.
3.

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?
YesNo

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?
YesNo

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?
YesNo

If yes, please describe:

Comments
Please list any questions or comments below

Thank you for taking the time to complete this form.