Agriculture Aviation Application

If you would like to request an online quote please complete the form below. This information is for internal use only; none of the following will be distributed to any other parties. See our privacy statement for more information.

   
*Owner's Name:
*Business Name:
Street Address:
*City:
*Province:
Postal Code:
   
*Please provide Email Address or Day Phone:  
Email Address:
Day Phone:
Fax:
   
Underwriter:
Expiration Date:
   
What Aircraft do you have?  
Year/Make/Model N No. Insured $
Value		 Hours Per Yr.
   
Where are they based?  
Airport Name:
Length:
Surface:
Hangared    Tied Down
   
Airport Name:
Length:
Surface:
Hangared    Tied Down
   
Is there a Lien Holder?  
Name:
Lien Amount:
On which Aircraft?: First    Second
   
Aircraft Special Uses (Any other than AG)
Spray Pattern Testing: Yes    No
   
Liability Coverage Requested  
   
Limits: $1,000,000 bodily injury and property Damage
$2,000,000 bodily injury and property Damage
   

Territory required:

 

Canada only
Canada and continental USA (excluding Alaska)
   
Passenger Seat??
Chemical Category: Excluding Chemical
Comprehensive Chemical - Limit of Chemical: $
Additional Coverage: Adjacent Crops
Crops Being Treated
Other:
   
Pilot Information  
#1 Pilot Name:  
Occupation:  
Date of Birth:   / /
Type of License:   Student  PVT  COML  ATP    Additional Ratings:   IFR    ME
Total Hours Retract Gear Multi Engine Tail Wheel Turbine Last 12Months In this Model
   
#2 Pilot Name:  
Occupation:  
Date of Birth:   / /
Type of License:   Student  PVT  COML  ATP    Additional Ratings:   IFR    ME
Total Hours Retract Gear Multi Engine Tail Wheel Turbine Last 12Months In this Model
   
#3 Pilot Name:  
Occupation:  
Date of Birth:   / /
Type of License:   Student  PVT  COML  ATP    Additional Ratings:   IFR    ME
Total Hours Retract Gear Multi Engine Tail Wheel Turbine Last 12Months In this Model
   
#4 Pilot Name:  
Occupation:  
Date of Birth:   / /
Type of License:   Student  PVT  COML  ATP    Additional Ratings:   IFR    ME
Total Hours Retract Gear Multi Engine Tail Wheel Turbine Last 12Months In this Model
   
History/ Miscellaneous  
Give particulars of accidents, claims and/or certificate suspensions of pilots and applicant over the last five years:
Area of Operation:
Years in Business:
Provincial Certificates required:
Are you an AAAA Member? Yes     No
Please let us know how you heard about us:
    Other: