Edward Jones Risk Placement| Insurance for Comprehensive Risk Management Solutions
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Edward Jones Risk Placement
AA
— A USA CORPORATION

Welcome to Edward Jones Risk Placement Online Quote Page.

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Please fill out the following information completely. Choose the limits and coverage to meet your needs and then submit for a quote and we'll handle the rest! You may contact us to customize any policy to suit your specific needs!


This quote request for is for the following:



Policy #

Personal Information: (*) Required information. Any fields omitted may delay quote

* Full Name:
* Street Address: Apt. No:
* City: * State * Zip: -
Work Phone: Fax:
Home Phone: Fax:
E-mail:
* Prefered method of contact: If "Other", specify:

Business or Occupation of Applicant:

Applicant Is:

If the applicant is other than individual, list all owners, directors, or officers:

Member of any Aircraft Association (such as AOPA, EAA, Etc.)?

Member #:

Insurance requested from 12:01 AM to 12:01 AM


Aircraft and Use Information
Liability Coverage Limits of Liability Desired
Each Passenger Each Occurance

Single Limit Bodily Injury and Property Damage Liability

Passengers:
$ $

Medical Expenses

Passengers:
$ $

Other Coverages (if any):

* Aircraft Uses: (Choose all that apply)

List and Describe all other uses not indicated above:

* Aircraft Information:

Aircraft #1:

FAA Reg. Number: Seating Cap. (Crew) (Pass)

* 1) N#: Make: Model: Horsepower: Year: Lienholder: Aircraft Type: Purch. New/Used: Purch. Date: Engine Hours since new or Last Major Overhaul: Number of hours flown on aircraft in last 12 months: Price Paid By Applicant (incl. extras): $ Present Est. Value (incl. extras): $

Aircraft Equipment List & Upgrades with Details:

Amount of Insurance: $

Add another aircraft

Hull Coverage



Deductible
In Motion


Not in Motion
$

Is aircraft operational and airworthiness certificate in full force and effect?
If 'no', explain:

Is the aircraft operated under a FAA standard airwothiness certificate?
If 'no', explain:

Aircraft based and at:
Airport: City: State:

Airport Type:

Tower:

Runway Lights:

Paved Runways: Length:

Elevation:

Applicant Is:




Lessor and Terms of Lease:

"Breach of Warranty" is


Pilot Log & Record Information
Pilot #1:

* Name: Date of Birth: -- (m-d-y)

FAA Pilot Certificate Number:

Medical Certificate Date of Physical/Class: -- (m-d-y)

Date of Biennial Flight Review: -- (m-d-y)

Ratings/Certificates (Choose all that apply)
Total Logged Hours
* Total Time: Tail Wheel: Retract Gear:
Multi-Engine: Turbine: In Aircraft To Be Insurred
Past 3 Months: Past 12 Months:

List any formal flight Training Facilities Attended, Aircraft model, and Date Attended:

Add another pilot

Do any pilots named above have any physical impairments?

Do any pilots named above have any waivers, limitations, conditions attached to their medical certificates?

Has an FAA or Military Pilot Certificate held by any pilot named above ever been suspended or revoked? If so, explain

Has any pilot named above ever been cited for any violation of Federal Air Regulations? If so, explain

Has any pilot named above ever been involved in any aircraft accident?

If so, explain

Has any applicant, officer or partner thereof, or pilot named above ever been indicted for or been arrested for a felony, drunk driving or reckless driving?

If so, explain

Has any applicant, officer or partner thereof, or pilot named above ever been convicted in or indicted in a legal action involving drugs?

If so, explain

Are there any other aircraft owned by the applicant?

If yes, please indicate year, make & model

Loss History and Previous Aviation Insurance

Has applicant had any aircraft/aviation losses, claims or incidents during the last 5 years?

If so, explain

Has any insurer canceled, declined, sent notice of cancellation, or refused to renew any aviation insurance?

If so, explain

Name of Present or Last Ins. Company:
Expiration Date: -- (m-d-y)


Any additional information or comments may be made here:
-- Please take a moment to review all of the information. Any missing or incorrect information could cause delays in quote and process time. Thank you. --

Any Person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

All particulars herein are warranted true and complete to the best of my/our knowledge and no information has been withheld or suppressed and I/we agree that this Application and the terms and conditions of the policy in use by the insurer shall be the basis of any contract between me/us and the Insurer. I hereby authorize this Company to investigate all or any qualifications or statements contained herein.

This application does not commit the Company to any liability nor make the Applicant liable for any premium unless the Company agrees to effect this insurance.

"Edward Jones Risk Placement Corporation
for Comprehensive Risk Management Solutions"

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