Florida Hangar Insurance Program
6719 Winkler Rd., Ste 216, Fort Myers, FL 33919  ~ 1-866-575-3022

 General Information
  Exact Name of Applicant: Submitted Date:  
  Street or P.O. Box: Effective Date:  
  City:  State:   Zip:   
  Contact: Telephone:  
  Business or occupation of applicant:  

 Property Description & Coverage Schedule: Deductible: 
  Location/Building #1 Location/Building #2 Location/Building #3
  Building            
  Contents            
  Tools            
  Mobile Equipment            
              
              
  Area in Square Feet            
  Type Construction - Building            
  Type Construction - Roof            
  Year Construction - Building            

 Airport Name: Identifier:
 Address of Building:
 Protection Class:

Airport Fenced:

 Yes
No		 Alarm 
System:		 Yes
No		 Type:
 Fire Department on Airport: Yes
No

Distance to Fire 
Department:
Tower: YesNo
Hours:  
Repair and Service Work in Hangar: YesNo
Describe:
Painting in Hangar: YesNo
Describe:
Occupancy (Type of Contents kept in Building):
Name and Address of Mortgagee:

 Prior Insurance (Last 3 years):
Policy Term Name of Company Policy Number Premium
       
       
       

Loss Detail (Last 3 years):
Agent's Comments & Recommendations:

Agency Name:

Agency Contact:
Phone:
Fax:
E-Mail:

CONTACT US TOLL FREE AT 866-575-3022