Northstar Aviation Insurance, Inc.
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Contact Information
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Name Insured:
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Title
First Name
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Last Name
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Suffix
Email
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Phone
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Address
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City
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State
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Alabama
Alaska
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Texas
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Zip Code
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Other Phone
(Work / Mobile / Etc)
Insured's Occupation
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Current Aircraft & Insurance Info
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are required.
Expiration Date of Current Policy
Current Insurance Carrier
Aircraft Use
Aircraft Purchase Date
FAA Aircraft N-Number
Year
Make/Model
Total Seats
Liability Limits Desired
Hull Value of Aircraft
Current Lienholder
Base Airport
Is Aircraft Hangared?
Yes
No
Number of Pilots
Select the total number of pilots. If there are more than five pilots total, please contact us at (701) 235-2041. Thanks!
Select Number of Pilots
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1
2
3
4
5
Pilot 1 Information
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( * )
are required.
Pilot Name:
*
Title
First Name
*
Last Name
*
Suffix
Pilot Date of Birth
*
Certificate/Ratings
Total Flight Time
Hours Flown Retractable Gear
Hours Flown Multi-Engine
Hours Flown Turbo-Prop
Hours Flown Multi-Engine Turbo-Prop
Hours Flown Jet
Hours Flown Multi-Engine Jet
Hours Flown Tail-Wheel
Hours Flown Seaplane
Sailplane time
Piston Rotor Wing time
Turbine Rotor Wing time
Total Hours Flown Past 12 Months
Recurrent Training In Last 12 Months
Hours In This Make/Model to be Insured
Hours (Last 12 Months In This Make/Model to be Insured)
Any incidents, accidents, insurance claims, violations, medical issues, DUIs, felonies:
Date of Last Medical Evaluation
Date of Last Biennial Flight Review (BFR)
AOPA Number
EAA Number
Pilot 2 Information
Fields marked with an asterisk
( * )
are required.
Pilot Name:
*
Title
First Name
*
Last Name
*
Suffix
Pilot Date of Birth
*
Certificate/Ratings
Total Flight Time
Hours Flown Retractable Gear
Hours Flown Multi-Engine
Hours Flown Turbo-Prop
Hours Flown Multi-Engine Turbo-Prop
Hours Flown Jet
Hours Flown Multi-Engine Jet:
Hours Flown Tail-Wheel
Hours Flown Seaplane
Sailplane time
Piston Rotor Wing time
Turbine Rotor Wing time
Total Hours Flown Past 12 Months
Recurrent Training In Last 12 Months
Hours In This Make/Model to be Insured
Hours (Last 12 Months In This Make/Model to be Insured)
Any incidents, accidents, insurance claims, violations, medical issues, DUIs, felonies:
Date of Last Medical Evaluation
Date of Last Biennial Flight Review (BFR)
AOPA Number
EAA Number
Pilot 3 Information
Fields marked with an asterisk
( * )
are required.
Pilot Name:
*
Title
First Name
*
Last Name
*
Suffix
Pilot Date of Birth
*
Certificate/Ratings
Total Flight Time
Hours Flown Retractable Gear
Hours Flown Multi-Engine
Hours Flown Turbo-Prop
Hours Flown Multi-Engine Turbo-Prop
Hours Flown Jet
Hours Flown Multi-Engine Jet
Hours Flown Tail-Wheel
Hours Flown Seaplane
Sailplane time
Piston Rotor Wing time
Turbine Rotor Wing time
Total Hours Flown Past 12 Months
Recurrent Training In Last 12 Months
Hours In This Make/Model to be Insured
Hours (Last 12 Months In This Make/Model to be Insured)
Any incidents, accidents, insurance claims, violations, medical issues, DUIs, felonies:
Date Of Last Medical Evaluation
Date Of Last Biennial Flight Review (BFR)
AOPA Number
EAA Number
Pilot 4 Information
Fields marked with an asterisk
( * )
are required.
Pilot Name:
*
Title
First Name
*
Last Name
*
Suffix
Pilot Date of Birth
*
Certificate/Ratings
Total Flight Time
Hours Flown Retractable Gear
Hours Flown Multi-Engine
Hours Flown Turbo-Prop
Hours Flown Multi-Engine Turbo-Prop
Hours Flown Jet
Hours Flown Multi-Engine Jet
Hours Flown Tail-Wheel
Hours Flown Seaplane
Sailplane time
Piston Rotor Wing time
Turbine Rotor Wing time
Total Hours Flown Past 12 Months
Recurrent Training In Last 12 Months
Hours In This Make/Model to be Insured
Hours (Last 12 Months In This Make/Model to be Insured)
Any incidents, accidents, insurance claims, violations, medical issues, DUIs, felonies:
Date Of Last Medical Evaluation
Date Of Last Biennial Flight Review (BFR)
AOPA Number
EAA Number
Pilot 5 Information
Fields marked with an asterisk
( * )
are required.
Pilot Name:
*
Title
First Name
*
Last Name
*
Suffix
Pilot Date of Birth
*
Certificate/Ratings
Total Flight Time
Hours Flown Retractable Gear
Hours Flown Multi-Engine
Hours Flown Turbo-Prop
Hours Flown Multi-Engine Turbo-Prop
Hours Flown Jet
Hours Flown Multi-Engine Jet
Hours Flown Tail-Wheel
Hours Flown Seaplane
Sailplane time
Piston Rotor Wing time
Turbine Rotor Wing time
Total Hours Flown Past 12 Months
Recurrent Training In Last 12 Months
Hours In This Make/Model to be Insured
Hours (Last 12 Months In This Make/Model to be Insured)
Any incidents, accidents, insurance claims, violations, medical issues, DUIs, felonies:
Date Of Last Medical Evaluation
Date Of Last Biennial Flight Review (BFR)
AOPA Number
EAA Number
If you have additional pilots please contact us at 972.250.0400. Thanks!
Comments
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Comments
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