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North Georgia Sport Planes

Insurance

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Contact Info

Two insurance providers are available:
 

Ladd Gardner

Falcon Insurance Agency, Inc.

lgardner@falconinsurance.com or 866-647-4EAA (4322) M-F 8:00AM-5:00PM Central

AND

 


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)