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Corporate Aircraft Insurance Quote

Registered Owner (s)
Last Name: First Name:
Street Address:
City: State:
Zip Code:
Work Phone: Home Phone:
Email Address: Fax Number:
   
How did you hear
about us?
Occupation:
Present Insurance Company:
Expiration Date of Current Policy:
Check this box if this is a new purchase:
AOPA Number:
   

Aircraft Insurance Quote
N#:
Year:
Make:
Model:
Total Seats:
Insured Value: $
Base Airport Identifier:
Base Airport Name:
Method of Storage:  Hangared
 Tied Down
Type of Use:
Other (Please Specify)
Lienholder:
Amount of Loan: $
   

Pilot Information
Pilot 1  
First Name:
Last Name:
DOB:
License Type:
Ratings
(Please choose all that apply):		 IFR
Sea
Multi-engine
Rotor
CFI
Any aviation accidents, waivers, violations, losses, incidents, DUI, DWI's? Yes No
If yes, please advise the detail and remember to include the date of the loss and the amount paid out by the insurance company.
 
Logged Pilot Hours for Pilot 1
Total Hours:
In this model:
Retractable Gear:
Multi-Engine:
Tailwheel:
Turboprop:
Turbine Jet:
Rotor:
Seaplane:
Other:
Last 12 Months:
Last School Attended in the
Make and Model?
When?
Where?
   
Pilot 2  
First Name:
Last Name:
DOB:
License Type:
Ratings
(Please choose all that apply):		 IFR
Sea
Multi-engine
Rotor
CFI
Any aviation accidents, waivers, violations, losses, incidents, DUI, DWI's? Yes No
If yes, please advise the detail and remember to include the date of the loss and the amount paid out by the insurance company.
 
Logged Pilot Hours for Pilot 2
Total Hours:
In this model:
Retractable Gear:
Multi-Engine:
Tailwheel:
Turboprop:
Turbine Jet:
Rotor:
Seaplane:
Other:
Last 12 Months:
Last School Attended in the
Make and Model?
When?
Where?
   
Pilot 3  
First Name:
Last Name:
DOB or Age:
License Type:
Ratings
(Please choose all that apply):		 IFR
Sea
Multi-engine
Rotor
CFI
Any aviation accidents, waivers, violations, losses, incidents, DUI, DWI's? Yes No
If yes, please advise the detail and remember to include the date of the loss and the amount paid out by the insurance company.
 
Logged Pilot Hours for Pilot 3
Total Hours:
In this model:
Retractable Gear:
Multi-Engine:
Tailwheel:
Turboprop:
Turbine Jet:
Rotor:
Seaplane:
Other:
Last 12 Months:
Last School Attended in the
Make and Model?
When?
Where?
   

Coverages
Liability Limits Requested:  
$1,000,000 Combined Single Limit including $100,000 per passenger
$1,000,000 Combined Single Limit with no passenger limitation
Other (Specify)
 
All pilots above have a valid and effective pilot certificate:
Yes
No
Do you own any other aircraft?   Yes No

Comments

  
Please list any comments or questions here: