D.R. Cox & Company, Inc.

Exact Name of Aircraft Owner

Pilot Information:

Name

Address

City

State

Zip

Occupation

Age

Email

Contact Number

License and Ratings

Total Hours Logged

Total Hours Logged in Last 12 Months

Total Hours Logged in Make/Model

Formal Schools or Training:

Any Accidents/Violations/Waivers? YesNo

If Yes, please explain

Aircraft Information:

Year

Make

Model

FAA Registration Number

Total Seats

Use:

Select OnePleasure & BusinessIndustrial AidPro PilotInstruction/Rental

Hull Value

Base Airport:

Airport Name

ID

Runway Length

PavedHangared

Limits of Liability (select one or more)

$1,000,000 Each Occurrence - $100,000 Each Passenger$1,000,000 Each Occurrence - $200,000/$250,000 Each Passenger$1,000,000 Each Occurrence - No Passenger Limitation

Other: