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Cirrus Insurance

Powered by Wings Insurance

1Basic Information

2Aircraft

3Pilot Info

4Additional Information

Full Name *

Street Address *

City *

State *

Please enter your two letter State code. E.g. "MN" instead of "Minnesota'

Zip/Postal Code *

Cell Phone *

Email *

Projected Delivery Date *

Please enter in MM/DD/YYYY format

Year *

Model *

N-Number

If unknown, please enter NTBD

Purchase Price *

Base Airport ID *

Will the aircraft be hangared at the base airport? *

Yes
No

Do you currently own this aircraft? *

Yes
No

How Many Pilots? *

Press to select (1-5)

Pilot 1

Full Name (Pilot 1) *

Date of Birth (Pilot 1) *

Please enter in MM/DD/YYYY format

License Type (Pilot 1) *

IFR Rated? (Pilot 1) *

Yes
No

Total Logged Hours (Pilot 1) *

SR20 Logged Hours (Pilot 1) *

SR22/SR22T Logged Hours (Pilot 1) *

SF50 Logged Hours *

Turbine Logged Hours *

Total Hours Logged in the Last 12 Months (Pilot 1) *

Date of Last Medical Certificate (Pilot 1)

Any Medical Limitations (if yes, explain below) (Pilot 1)

Yes
No

Any aviation accidents, incidents, waivers, violations, losses, DUI's, Felonies, etc.? (Pilot 1) *

Please enter 'None' if not applicable

Pilot 2

Full Name (Pilot 2) *

Date of Birth (Pilot 2) *

Please enter in MM/DD/YYYY format

License Type (Pilot 2) *

IFR Rated? (Pilot 2) *

Yes
No

Total Logged Hours (Pilot 2) *

SR20 Logged Hours (Pilot 2) *

SR22/SR22T Logged Hours (Pilot 2) *

SF50 Logged Hours (Pilot 2) *

Turbine Logged Hours (Pilot 2) *

Total Hours Logged in the Last 12 Months (Pilot 2) *

Date of Last Medical Certificate (Pilot 2)

Any Medical Limitations (if yes, explain below) (Pilot 2)

Yes
No

Any aviation accidents, incidents, waivers, violations, losses, DUI's, Felonies, etc.? (Pilot 2) *

Please enter 'None' if not applicable

Pilot 3

Full Name (Pilot 3) *

Date of Birth (Pilot 3) *

Please enter in MM/DD/YYYY format

License Type (Pilot 3) *

IFR Rated? (Pilot 3) *

Yes
No

Total Logged Hours (Pilot 3) *

SR20 Logged Hours (Pilot 3) *

SR22/SR22T Logged Hours (Pilot 3) *

SF50 Logged Hours (Pilot 3) *

Turbine Logged Hours (Pilot 3) *

Total Hours Logged in the Last 12 Months (Pilot 3) *

Date of Last Medical Certificate (Pilot 3)

Any Medical Limitations (if yes, explain below) (Pilot 3)

Yes
No

Any aviation accidents, incidents, waivers, violations, losses, DUI's, Felonies, etc.? (Pilot 3) *

Please enter 'None' if not applicable

Pilot 4

Full Name (Pilot 4) *

Date of Birth (Pilot 4) *

Please enter in MM/DD/YYYY format

License Type (Pilot 4) *

IFR Rated? (Pilot 4) *

Yes
No

Total Logged Hours (Pilot 4) *

SR20 Logged Hours (Pilot 4) *

SR22/SR22T Logged Hours (Pilot 4) *

SF50 Logged Hours (Pilot 4) *

Turbine Logged Hours (Pilot 4) *

Total Hours Logged in the Last 12 Months (Pilot 4) *

Date of Last Medical Certificate (Pilot 4)

Any Medical Limitations (if yes, explain below) (Pilot 4)

Yes
No

Any aviation accidents, incidents, waivers, violations, losses, DUI's, Felonies, etc.? (Pilot 4) *

Please enter 'None' if not applicable

Pilot 5

Full Name (Pilot 5) *

Date of Birth (Pilot 5) *

Please enter in MM/DD/YYYY format

License Type (Pilot 5) *

IFR Rated? (Pilot 5) *

Yes
No

Total Logged Hours (Pilot 5) *

SR20 Logged Hours (Pilot 5) *

SR22/SR22T Logged Hours (Pilot 5) *

SF50 Logged Hours (Pilot 5) *

Turbine Logged Hours (Pilot 5) *

Date of last Medical Certificate (Pilot 5)

Any Medical Limitations (if yes, explain below) (Pilot 5)

Yes
No

Any aviation accidents, incidents, waivers, violations, losses, DUI's, Felonies, etc.? (Pilot 5) *

Please enter 'None' if not applicable

Any additional information you'd like to provide?

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