MacKenzie Aviation - Nonowned Quote Form

If you own your craft, please see our Online Quote Form page. You can download a file of this application if you prefer or try one of our other options. Please read the ENTIRE application before you submit it to us.

SPECIAL NOTE: Before filling out and submitting the application please read the following: This form is provided as a courtesy and to help expedite the application process. However, in order to BIND a policy you must send an original, signed application along with payment. A signed, faxed copy of this application to us along with payment is sufficient to begin the process, however, the underwriters require an original. You may continue with this application at this time assured that we will make the process quick and easy -OR- you may download a file of this application, print it, fill it out and submit it -OR- you may opt to contact us for other options such us having us send you the application.

Application for Non-Owned Aircraft Liability and Aircraft Damage Liability

This application is for personal renters and flight instructors. I desire insurance to cover my activities as a (select one):

Personal Renter – This application is for your personal and business related use of non-owned, fixed wing, non-pressurized, land aircraft having a non-turbine single engine of 450 horsepower or less (including non-powered sailplanes) and a capacity of no more than seven (7) total passengers and / or seats and having a standard airworthiness certificate.

Flight Instructor – This application is for your personal, business-related flying, and your flight instruction to others in non-owned, fixed wing, non-pressurized, land aircraft having a non-turbine single engine of 450 horsepower or less (including non-powered sailplanes) and a capacity of no more than seven (7) total passengers and / or seats and having a standard airworthiness certificate.

*Pilot Information:

Pilot Name (Individual Name):	Age:
Address:	Apt. No:
City: State:
Home Phone:	Work Phone:
Occupation:	Employer:
E-mail Address:

Log & Record Information:

License and Ratings: (Choose All That Apply)
	License	Ratings/Certificates	Log	Hours
	Private	IFR	*Total Time:
	Commercial	Single Engine Land	Last 12 Months:
	Student	Multi-Engine Land
	ATP	Single Engine Sea	Flight Instructing:
		Helicopter	Last 12 Months:
		Glider
		CFI
		CFII
		CFMEI
	What type of aircraft do you usually fly? Make: Model:		Hours as PIC in type:


* Within the last 36 months have you?	Yes No
Been involved in any aircraft accident/incident?
Been cited for any FAR violations?
Had your pilot's or driver's license suspended?
Been convicted of any felony or DUI charge?

If you answered “yes” to any of the above, please explain below: NOTE: Contacting MacKenzie Aviation via phone may be required.

Liability Coverage - Pays for bodily injury and property damage for which you are legally liable arising out of you use of non-owned aircraft, but excluding physical damage to non-owned aircraft.

Renters

Select Coverage	Each Occurrence	Passengers	Premium
	$250,000	$25,000	$125
	$500,000	$50,000	$160
	$500,000	$100,000	$230
	$1,000,000	$100,000	$325
Add my employer as an Additional Insured: $50

Flight Instructor

Select Coverage	Each Occurrence	Passengers	Premium
	$250,000	$25,000	$225
	$500,000	$50,000	$425
	$500,000	$100,000	$650
	$1,000,000	$100,000	$875
Add Comprehensive CFI Liability Coverage: $ 75 **
Add my employer as an Additional Insured: $50 *

Physical Damage to Your Non-Owned Aircraft - Pays for physical damage to non-owned aircraft for which you are legally liable.

Select Limit	Physical Damage Limit	Premium
	$10,000	$175
	$20,000	$250
	$40,000	$450
	$60,000	$600
	$80,000	$775
	$100,000	$975
	$150,000	$1,425
	I do not wish to purchase this coverage

**This coverage may be purchased to protect you against claims arising from your professional obligations as a CFI for instruction you have given within the 12 months prior to the date of a covered occurrence.

*Your employer may require this coverage if you use non-owned aircraft on company business. This coverage is not available to Student or Recreational pilots. Coverage does not apply to employers who are: involved in the manufacture, building, designing, selling, or distribution of aircraft, aircraft engines, parts, accessories, components, or fuel; engaged in the operation of an aircraft repair shop, sales agency, rental service, flight school, pilot training center or any other commercial flying service.

AGENT : MacKenzie Aviation Insurance Agency, Inc.

P.O. Box 1425, Painesville, OH 44077

Phone: 440-357-9110 Fax: 440-357-9171

1-800-354-5253 www.mackenzieaviation.com

NOTE: Please read the following but note that you cannot fill out any information beyond this point. This is because you must fill out this information on an original copy (we'll supply after you submit application or you can download it) and submit along with payment in order to bind coverage.

I would like to begin coverage on _______________________ for one year. I understand that coverage shall not be effective until the company has accepted by application and premium payment has been received in full through a producer appointed by AIG Aviation. I also understand that my actual policy will have terms and conditions not found in this general description. I warrant that all of the information in this application is true and complete to the best of my knowledge.

I have enclosed a check payable to my agent in the amount of $_____________. (Residents of Kentucky and West Virginia please contact your agent prior to mailing this for the required addition of state taxes.) I understand that once coverage is bound, a minimum of 50% of the premium is fully earned.

Your Signature____________________________________ Today’s Date_________________________

Some states require that we notify you that any person who knowingly and with intent to defraud any insurer, or other person, files an insurance application containing false or misleading information or any fact material thereto, commits a fraudulent insurance act which is a crime.

Please take a moment to review this application. It is imperative that all the information is filled out correctly and that you have read this ENTIRE application.

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