Helicopter Operations 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:  
Street Address:  
*City:  
Province:  
Postal Code:  
*Please provide Email Address or Day Phone:
Email Address:  
Day Phone:  
Fax:  
   
Present Insurance Company
   
Underwriter:  
Expiration Date:  
   
Describe your Aircraft
   
Registration letters:  
Year:  
Make:  
Model:  
Insured Value:  
Total Seating [ ] Crew + [ ] Passengers:  
Land     Sea     Amphib
   
Where is your Aircraft Based?
   
Airport:
City/Provice:
Airport ID:
Hangared     Tied Down
   
Aircraft Use Pleasure & Business
Industrial Aid (Pro-flown)
Other:
   
Lien Information:  
   
Lien Holder:  
Lien Amount:  
   
Limits of Liability (Indicate Quote Requests)
   
$1,000,000 with sublimit of $300,000 Each passenger
$1,000,000 Each Occurrence - No Passenger Limitation
$2,000,000 Each Occurrence – No passenger limitation
Other (please explain):
   
Territory required:  
Canada only  
Canada and continental USA (excluding Alaska)  
   
#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
 
Annual Proficiency Training Yes No
   
If Yes, please describe Training:
   
Date of Training: / /
   
Please let us know how you heard about us:
  Other:
   
History/ Miscellaneous  
Give particulars of accidents, claims and/or certificate suspensions of pilots over last five years:


If this form is being filled out by a broker, please fill out the following information.

Name of Brokerage:

Contact:

Phone #:

Email address: