PIM Aviation Insurance
P.O. Box 12750
Wichita, KS 67277
Local: (316) 942-0699
Toll free: (800) 826-4442
Facsimile: (316) 942-1260

If you would like to request an online quote please complete the form below. This information is for internal use only; none of the following will be distributed to any other parties. See our privacy statement for more information.

*Name of Insured:
Street Address:
*City:
*State:
Zip:
*Please provide Email Address or Day Phone:
Email Address:
Day Phone:
Fax:
Name and addresses of all subsidiary corporations to be covered:

Management Personnel: Individual     Corporation     Partnership
Other:


Name

Age

Position and Duties
Years Experience
as Operator

Applicant is:
F.A.A. Approved - Repair Station, Number:

V.A. Approved - Flight School:
Ground School:

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