MacKenzie Aviation - Policy information for current clients

Dear Valued Customer,

Would you like to update your pilots' log, or let us know about your change-of-address? Maybe you just have a question on your existing policy. We make it easy for you with this form. You can ask for policy information or let us know of any changes or updates that you'd like to make to your policy. If you need a quote, you can visit our Online or Offline quote pages, or even our Non-Owned quote page. Of course, you can contact us for any of the above reasons, or just to say "hello".

You may fill out only the information you need. See the instructions below.

This form is for the following:

Request information on existing policy -OR- update personal information only

Change/Update current policy (coverage, log, hangar location, etc.)

Policy #

Personal Information: (Please check the box for any changes to info)

* Full Name:
* Street Address:		Apt. No.
* City:		* State
* Zip/Postal Code:	-
Work Phone:		Fax
Home Phone:		Fax
E-mail:

* Preferred method of contact: If 'Other', specify:

Comments, or specific information requested:

If you are only requesting information on your existing policy, or making only personal information changes then you may submit this form now.

The following is only required if you would like to make changes to your current policy (i.e. increase your coverage, or update your pilots' log). Fill out only the information that you wish to change or modify.

Airport and Aircraft Storage Information:

Name of Airport: Runway Length (ft.):
Location of Airport (City): State:
Runway surface: How is the aircraft stored:

Aircraft and Use Information:

Liability Amounts:
	Each Occurrence:	Each Passenger:
	Medical Pay:	Hull: $ (Craft Value)

Aircraft Uses: (Choose all that Apply)
	Pleasure & Business	Instruction & Rental	Aerial Photography
	Banner Towing	Charter	Flying Club
	Patrol Flights	Crop Dusting	Other

Aircraft Information:
1. N#:	Make:	Model:	Horsepower:	Year:
Lienholder:		Amount: $	Value: $	Seats:

2. N#:	Make:	Model:	Horsepower:	Year:
Lienholder:		Amount: $	Value: $	Seats:

NOTE: Need to add more aircraft?

Pilot Log & Record Information:

Pilot #1:
Name: Date of Birth: -- m/d/y
Occupation: Medical Due Date: -- BFR Due Date: --

License and Ratings: (Choose All That Apply)
	License	Ratings/Certificates	Log	Hours
	Private	IFR	Total Time:
	Commercial	Single Engine Land	Retractable Gear:
	Student	Multi-Engine Land	Multi-Engine:
	ATP	Single Engine Sea	Tail Wheel:
		Helicopter	Make/Model:
		Glider	Last 90 Days:
		CFI	Pressurized:
		CFII	Turbo-Prop:
		CFMEI

If applicable, advise flight school attended or any additional training or schooling.

Started: -- Ended: -- (m/d/y)

Accidents Violations Physical Defects Waivers DUIs Felonies

For each box checked, please indicate date and a brief explanation of the incident:

Pilot #2:
Name: Date of Birth: -- (m/d/y)
Occupation: Medical Due Date: -- BFR Due Date: --

License and Ratings: (Choose All That Apply)
	License	Ratings/Certificates	Log	Hours
	Private	IFR	Total Time:
	Commercial	Single Engine Land	Retractable Gear:
	Student	Multi-Engine Land	Multi-Engine:
	ATP	Single Engine Sea	Tail Wheel:
		Helicopter	Make/Model:
		Glider	Last 90 Days:
		CFI	Pressurized:
		CFII	Turbo-Prop:
		CFMEI

If applicable, advise flight school attended or any additional training or schooling.

Started: -- Ended: -- (m/d/y)

Accidents Violations Physical Defects Waivers DUIs Felonies

For each box checked, please indicate date and a brief explanation of the incident:

Any additional information or comments may be made here:

-- Please take a moment to review all of the information. Any missing or incorrect information could cause delays in quote and process time. Thank you. --

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