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

Present Insurance Company (not agent)

Policy expiration date

Name of Airport

City and State

Comments
Please describe the nature of your business:

Please Check the Box Next to Your Desired Coverages

Slip and fall on your premises - Airport Premises Liabiliy CoverageSale of aircraft, fuel, etc.- Products Liability CoverageBailment of aircraft you do not own, lease or consign - Ground Hangarkeepers Liability CoverageMinor injuries on your premises - Premises Medical CoverageOperation of owned, leased or consigned aircraft - Owned Aircraft Liability and Hull Insurance CoverageOperation of aircraft you do not own, lease or consign - Non-Owned Aircraft Liability and Hull Insurance CoverageFire on Building and/or Contents - A Property Insurance Policy

Do you own or lease any aircraft?
YesNo
Comments
Please list any questions or comments below

Thank you for taking the time to complete this form.