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COPA Preferred Insurance Program Application


News   Application

Apply for the COPA Preferred Insurance Program today. Complete the form below, or download the application and fax to us at 636-532-3646.

Insured Name:
(Should match FAA Registration)
You Are:
Occupation/Business:
Address:
City/State:
Zip:
Phone:
Email:
Your Present Insurer:
Policy Expiration Date:
COPA Member: Yes No
COPA Screen ID:

Aircraft Information

Aircraft Year/Make/Model:
FAA Number:
Total Seats:
Insured Value:
Physical Damage Coverage Type:
Aircraft Based At:
Is The Aircraft Hangared? Yes No
Lienholder Name and Address (if Applicable):
Liability Limited Requested:

Aircraft Operations

Will any charge (other than operating expenses) be made for use of the aircraft? Yes No
Will the aircraft be used for anything other than transporting people? Yes No
Will the aircraft be used anyplace other than at paved runways? Yes No
Will the aircraft be used outside the continental United States? Yes No
Will the aircraft be used for student or pilot instruction? Yes No
Do you own or exclusively lease any other aircraft? Yes No
Do you use non-owned aircraft? Yes No

Pilot Information

PILOT #1
First Name:
Last Name:
DOB:
Occupation:
Certificates Held:
Student
Private
Commercial
ATP
Ratings:
AMEL
Instrument
CFI
Last BFR Date:
Last Medical Date/Class:
Last CPPP Completion Date:
Last CDM Completion Date:
Last Sim Completion Date:
Last Training with Cirrus CFI:

Logged Pilot Hours:
Total Hours All Aircraft:
This Make and Model:
Hours Last 12 Months:
Hours Last 90 Days:
PILOT #2
First Name:
Last Name:
DOB:
Occupation:
Certificates Held:
Student
Private
Commercial
ATP
Ratings:
AMEL
Instrument
CFI
Last BFR Date:
Last Medical Date/Class:
Last CPPP Completion Date:
Last CDM Completion Date:
Last Sim Completion Date:
Last Training with Cirrus CFI:

Logged Pilot Hours:
Total Hours All Aircraft:
This Make and Model:
Hours Last 12 Months:
Hours Last 90 Days:

PILOT #3
First Name:
Last Name:
DOB:
Occupation:
Certificates Held:
Student
Private
Commercial
ATP
Ratings:
AMEL
Instrument
CFI
Last BFR Date:
Last Medical Date/Class:
Last CPPP Completion Date:
Last CDM Completion Date:
Last Sim Completion Date:
Last Training with Cirrus CFI:

Logged Pilot Hours:
Total Hours All Aircraft:
This Make and Model:
Hours Last 12 Months:
Hours Last 90 Days:
Have any of the pilots had any accidents, incidents, claims or citations for F.A.R. violations?
Yes No

Have any of the pilots had any license limitations or medical waivers?
Yes No

Have any of the pilots had any felony convictions or license suspensions arising out of operating a motor vehicle?
Yes No

Have any of the pilots been arrested for operating a motor vehicle recklessly or while under the influence of alcohol or drugs?
Yes No
 

If yes, provide remarks in space provided (for losses/DUIs or any other information for each pilot):

By submitting this application, I agree that all of the information is true and correct and that no requested information has been omitted. I understand that this submitted application does not constitute a binder or agreement by any insurer to provide coverage.

Thank you for visiting NationAir's website!

 

 

 

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