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

Is policyholder a member of the Soaring Society of America?
YesNo

Occupation/Nature of business

Present Insurance Company (not agent)

Policy expiration date

Airport Name

Aircraft Schedule

* For Uses R= Rental/Instruction, T= Glider Tow for Hire
Applicable to Gliders and Tow Planes

FAA N#	Year Make & Model	Glider / Tow Plane Value	R	T	Others	Trailer Value
1.			Yes	Yes
2.			Yes	Yes
3.			Yes	Yes

Comments
Please list any questions or comments below

Thank you for taking the time to complete this form.