Aviation Insurance Services of Utah, Inc. 1912 Sidewinder Drive, Suite 105 Park City, Utah 84060 PHONE: (435) 645-8100 FAX: (435) 645-8137 Aircraft Insurance Application All fields required except those indicated in blue.

APPLICANT
ADDRESS
PHONE
FAX
EMAIL
BUSINESS OF APPLICANT
APPLICANT IS	Individual Corporation Partnership Other If other, explain
Insurance is requested from	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2002 2003 2004 2005 2006 2007 2008 2009 2010 To Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2002 2003 2004 2005 2006 2007 2008 2009 2010

Aircraft
Is aircraft operational and Airworthiness Certificate in full force and effect?	Yes No	If "NO" explain
Is the aircraft operated under a F.A.A. Standard Airworthiness Certificate?	Yes No	If "NO" describe category
Has aircraft (and/or engines) been modified:	Yes No	If "YES" explain
Is there any unrepaired damage to the aircraft (minor or major)?:	Yes No	If "YES" explain

Make & Model	Year	FAA Cert Number	Seating Capacity Crew	Seating Capacity Pass	Land Sea	Purchased New/Used	Purchased Date	Price Paid by Applicant	Present Value	Engine Hrs. Since new/ovhl
1st line required only							MM/DD/YY
			1 2	2 3 4 5 6 7 8 9 10 11 12	L S	New Used		$	$
			1 2	2 3 4 5 6 7 8 9 10 11 12	L S	New Used		$	$
			1 2	2 3 4 5 6 7 8 9 10 11 12	L S	New Used		$	$
			1 2	2 3 4 5 6 7 8 9 10 11 12	L S	New Used		$	$