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
First name:
Middle name:
Last name:
Address
Street
City:
State	Select State Alabama Alaska Alberta American Samoa Arizona Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Islands Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip:
Home phone:
Work phone:
Fax:
Email:
Date of birth:	//
Gender	Male Female
Insurance Information
Amount of insurance (minimum of $500,000)
Term lengths:	10yr 15yr 20yr 25yr 30yr
Tobacco use:	Yes No
If yes, type and amount:
Medications:
Rating:	Preferred Standard
Are you a pilot	Yes No

If yes, please complete below:...
PIM Aviation Insurance Aviation Questionaire
Type of license:	Student Recreational Private Commercial Airline Transport
Do you have a valid instrument rating?	Yes No
Number of annual hours flown as pilot or crew?	Last 12 months Last 12-24 months Expected in next 12 months
Purpose of current flying (please check all that apply):	Pleasure Business Commercial Military Other (give details)
Flying purpose details:
Will you be changing your flying activities in the future?	Yes No
If yes, give details:
Make and model of aircraft flown:
Total hours in aircraft currently flying:
Have you flown or do you contemplate flying an experimental/homebuilt aircraft?	Yes No
If yes, is it FAA certified?	Yes No
If yes, give details:
Indicate if you engage in any of the following aviation activities:	Charter Freight Transport Aerial Application Instruction Test Survey Sight Seeing Commercial Photography Mapping Aerobatics
Medical Certificate:	Class I Class II Class III
Date of last renewal:
Has medical certificate ever been denied?	Yes No
If yes, give details:
Have you ever had an accident, been grounded or fined for a violation of regulations?	Yes No
If yes, give details: