Aviation Insurance Quote Form

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or you may fill in the information, print the form from your browser window by clicking on the Printable Version button above, and mail or fax the form to:
Company Name, Street Address, City, State, Zip Code
Fax Number

* Denotes Required Field

General Information
*Name:
*Address:
*City:	*State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming   *Zip Code:
*Day Phone:	*Evening Phone:   Ex. 920-555-1212
Best Time to Call:	Select One Morning (8 a.m.-noon) Afternoon (noon-5 p.m) Evening (5 p.m.-9 p.m.)
*Contact E-Mail Address:
*Confirm E-Mail Address:

Current Aviation Insurance Information
Company Name (not agency):
Policy Expiration Date:	Ex. 01/15/2005
Premium Amount: $
Term:	6 Months 1 year Other

Aircraft Information
Aircraft #1:	Year:   Make:   Model:   Engine Type:
	Horsepower:   # of Seats:
	Date Purchased:  Ex. 01/15/2004
	Purchase Price: $   Present Value: $
	Aircraft Cat.: Exp.   Std.
	Aircraft Hangared at:
	Lienholder:
	Additional Insured/Address:
	FAA Reg. #:
Aircraft #2:	Year:   Make:   Model:   Engine Type:
	Horsepower:   # of Seats:
	Date Purchased:  Ex. 01/15/2004
	Purchase Price: $   Present Value: $
	Aircraft Cat.: Exp.   Std.
	Aircraft Hangared at:
	Lienholder:
	Additional Insured/Address:
	FAA Reg. #:
Aircraft #3:	Year:   Make:   Model:   Engine Type:
	Horsepower:   # of Seats:
	Date Purchased:  Ex. 01/15/2004
	Purchase Price: $   Present Value: $
	Aircraft Cat.: Exp.   Std.
	Aircraft Hangared at:
	Lienholder:
	Additional Insured/Address:
	FAA Reg. #:

Liability Limit for ALL Aircrafts
Bodily Injury:	Select One $25,000/50,000 $50,000/100,000 $100,000/200,000 $150,000/300,000 $250,000/500,000 $300,000/600,000 $500,000/1,000,000
Property Damage:	Select One $10,000 $25,000 $50,000 $100,000 $250,000 $300,000 $500,000
Per-Seat Medical:	Select One $50,000 $100,000 $300,000 $500,000 $1,000,000

Hull Coverage for ALL Aircrafts
Coverage Type:	Select One Ground & Flight
Amount Requested ($):

Pilots/Operators Information
(always list insured as Pilot #1)
Pilot/Operator #1:	Name:
	Date of Birth:  Ex. 01/15/1970
	Occupation:
	Ratings/Certificates:
	Logged Hours
	Tail Wheel:   Retract. Gear   In Model:   Last 12 Months:
Pilot/Operator #2:	Name:
	Date of Birth:  Ex. 01/15/1970
	Occupation:
	Ratings/Certificates:
	Logged Hours
	Tail Wheel:   Retract. Gear   In Model:   Last 12 Months:
Pilot/Operator #3:	Name:
	Date of Birth:  Ex. 01/15/1970
	Occupation:
	Ratings/Certificates:
	Logged Hours
	Tail Wheel:   Retract. Gear   In Model:   Last 12 Months:
List all claims, incidents, FAA medical waivers, FAA violations, DUI convictions & felony convictions
Pilot/Operator #1:
Pilot/Operator #2:
Pilot/Operator #3:

Miscellaneous Information
Aircraft Primary Use: Select One Business Pleasure Business & Pleasure Commercial
Passenger Charters:	Select One Yes No	Crop Dusting:	Select One Yes No
Flight Instructor:	Select One Yes No	Aircraft Based:	Select One Yes No
Aircraft Hangared:	Select One Yes No	On Floats:	Select One Yes No
Aircraft Tied Down:	Select One Yes No	Paved Runway:	Select One Yes No
Airport Name:		Airport Location:

Additional Comments

Please provide any additional comments that you feel would be appropriate for this quotation. If you have additional information to provide, where there were not enough fields above, such as additional drivers, vehicles, driver histories, etc., please enter it here

*Acknowledgment & Consent

I hereby certify that the above information is complete and accurate to the best of my knowledge. I hereby authorize the agency to obtain motor vehicle reports, loss reports and credit reports about me on an ongoing basis during this quotation and policy period and to check my motor vehicle and driving record on an ongoing basis during the term of the determination and policy period. The agency receiving this application will retain the application whether or not a policy is issued. The agency may rely on this application when determining the quotation and when deciding whether to issue a policy. False statements may subject me to criminal penalties. I authorize the agency to obtain a motor vehicle and driving record about me on an ongoing basis during this quotation and policy period and to check my motor vehicle and driving record on an ongoing basis during the term of the determination and policy period. If a policy is issued, I authorize the agency to give information about me to its affiliates. Yes No Enter your initials here:   Today's date: Ex. 01/15/2004

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