Lancair pilot insurance survey.

The purpose of this questionnaire is to build a database of information for all Lancair depositors/builders and Lancair pilots. This information will be used to determine if an affordable and dependable Lancair insurance "program" can be created and implemented for our customers. The information you provide is completely confidential and will not be disclosed to anyone other than Lancair and our insurance company. Please take the time to complete this form. If other pilots will be flying your Lancair, please have them complete a separate form. 




          Name: 
       Address: 
          City: 
         State: 
           Zip: 
 Daytime phone: 
           fax: 
e-mail address: 
    Occupation: 
           Age: 

Pilot certificate and please list ratings and endorsements: 

        Total time / time last 90 days: 
Total logged Lancair hours (all types): 
                    Total complex time: 
           Total high performance time: 
         Accidents / incidents / DUIs?: 
Initial or recurrent training in the last 12 months?:

            If yes, where and with who: 

                        Lancair model owned: 
                                    Flying?: 
       If flying, registration (FAA) number: 
                     Is this a partnership?: 
      if yes, please list partner's name(s): 
                  Are you currently insured? 
If yes, what insurance company (not agency): 
                  Is your Lancair hangared?: 
                          Liability premium: 
                               Hull premium: 
                            Expiration date: 
Please list the flying magazines you read most often: