The Avemco Team
www.avemco.com <
http://www.avemco.com>
Mail or fax to:
Avemco Insurance Company
411 Aviation Way
Frederick, MD 21701
Fax: 800-863-3338
AVEMCO
INSURANCE COMPANY
411 Aviation Way
Frederick, Maryland 21701
1-800-638-8440 Fax: 1-800-863-3338
SUPPLEMENTAL
APPLICATION FORM - (Amateur Built Experimental)
Name:__________________________ Address:_______________________________
City:
___________________ State: ____ Zip: _________ Home Phone:
____________
Employer____________________ Occupation:_________
Work Phone:____________
Email: _______________________________ Date of Birth: ___/___/___
Pilot
Cert. #__________________________ Date of Last BFR: ___/___/___
Medical Certificate: Date Issued ________________
Class:
______________________
Section A:
(To be completed by all applicants)
Aircraft Make and Model: __________________________Registration:
#____________
Date
of last Condition Inspection: ___/___/___
Have any modifications or changes been made to the aircraft structure,
components
or systems, other than those recommended by the kit/plan
manufacturer/supplier? If YES, please describe:
_________________________________________________________
______________________________________________________________________
______________________________________________________________________
Engine Make/Model/Horsepower:____________________________________________
Propeller Make/Model/Size: ________________________________________________
Have
any modifications or changes been made to the aircraft engine or
propeller? If YES, please describe:
____________________________________________________
______________________________________________________________________
Has
the engine been installed in accordance with the kit/plans
manufacturer's recommendations?
______________________________________________________
If this is an automobile engine conversion is it a firewall forward
installation from the manufacturer?
__________________________________________________________
Is
the aircraft equipped for IFR in accordance with FAR section
91.205?_____________
Is the aircraft currently operating
in Phase II of its operating
limitations?
If YES:
Proceed to Section "C" of this form If NO: Complete Section
"B" and "C" of
this form
Section B:
(To be completed by applicants in Phase I of the aircraft
operating
limitations)
Has the aircraft been test flown? ____________________________Date:
___/___/___
Did
you utilize the EAA's Technical Counselor Program?
_________________________
If YES, name of Technical Counselor:
________________________________________
Have
you participated in the EAA's Flight Advisor Program for this aircraft?
__________
If YES, name of Flight
Advisor:______________________________________________
Will
you be using a test pilot other than yourself? If YES, please provide
the following information:
Test pilot Name:_____________________
Address: ____________________________
City: ________________________ State/Province: ______________
Zip:___________
License,
Certificates, Ratings:
______________________________________________
Total Hours: ____________________________________________________________
Total
Tailwheel Hours: ____________________________________________________
Total Retract Gear Hours: _________________________________________________
Total Hours in this make/model of aircraft:
____________________________________
Has the Test Pilot participated
in the EAA's Flight Advisor program for this
aircraft or is the Test Pilot an EAA Flight Advisor?
________________________________________
Has
the Test Pilot within the past 90 days logged at least 5 hours as the
sole manipulator of the controls, including 3 take
offs and landings in an
aircraft of the same make and model as the insured aircraft?
______________________________________
SUPPLEMENTAL
APPLICATION FORM - (Amateur Built Experimental)
Section C:
(To be completed by all applicants)
Are you the sole
owner of the aircraft?
_______________________________________
Did any professional builder construct more than 20%
of this aircraft?
_______________
Do you hold a Repairman Certificate for the aircraft?
____________________________
How
many hours of flight time has this aircraft accumulated?
______________________
How many hours of flight time has this
engine and propeller combination
accumulated?___________________________________________________________
How many hours
do you have in this aircraft as Pilot In Command (sole
manipulator of the controls)?
___________________________________________________________
I
affirm that the answers given are true and complete to the best of my
knowledge and belief and that no material information
has been withheld. I
further acknowledge the following:
While my aircraft is being flown during Phase I of its
operating limitations
I understand there is no Occupant Liability Coverage. A test pilot is
considered an occupant
of the aircraft and coverage does not apply if he/she
sues the owner for Bodily Injury.
Even if I purchase hull coverage
Including Flight, I understand there is no
In-Flight hull coverage when my aircraft is flown during Phase I of the
operating
limitations unless:
1) The aircraft has already first successfully flown 10 hours,
including 10 take offs
and 10 full stop landings.
I authorize AVEMCO Insurance Company to investigate all or any
qualifications or statements
contained herein.
Date: ____________________________
Signed:_____________________________________
(Insured/Applicant)
This information becomes a part of the Insurance Application of:
__________________________ (Quote/Policy Number)
