Request an Aviation Quote Name* First Last Name you're called by A.A.A. NumberRenewal Date MM slash DD slash YYYY Email* Cell PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant is:* Individual Corporation Partnership Current or Past Insurance Company Present Insurance Expires* MM slash DD slash YYYY Name of Airport Airport Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Runway Length Aircraft is:* Hangered Tied-down Aircraft InformationAircraft Information Aircraft Make and Model "N" Number Year of manufacturing Landing Gear Current Value Engine Make and Horsepower Seats (including pilots) Type of airworthiness certificate Actions Edit Delete There are no Aircraft. Add Aircraft Maximum number of aircraft reached. Is the aircraft mortgaged?* Yes No If yes, what type of mortgage?* Loss Payable Clause Breach of Warranty Amount of Loan and Final Payment Name of Bank holding loan Bank Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pilot InformationPilot Information Name of Pilot Age Type of License Rating Date of last biennial flight Med Date Hours in Model 1 Hours in Model 2 (if applicable) Hours in Model 3 (if applicable) Hours in Model 4 (if applicable) Hours in Model 5 (if applicable) Tail Wheel (Fixed Gear) Tricycle (Fixed Gear) Retract Multi Engine Hours Total Hours Actions Edit Delete There are no Pilots. Add Pilot Maximum number of pilots reached. Do you use your plane(s) for any purpose other than pleasure or business?*(This is defined as personal and pleasure use and in direct connection with your business, excluding any operation for which a charge is made) Yes No Please also indicate if plane(s) are used for aerobatics or flybys.Coverages & Limits DesiredWhen passenger liability is provided, the passenger limit is $100,000/passenger with $5,000/personal medical payments. Higher limits are available. $1,000,000 $500,000 Hull CoverageAmount Desired No. 1 Amount Desired No. 2 Amount Desired No. 3 Amount Desired No. 4 Type of full coverage desired Not-in-motion coverage only Full Hull coverage (includes the not-in-motion) Restoration coverage only (airplane not flying) Not-in-motion-coverage only Full Hull coverage Value nowValue when doneLoss, History and Previous Aviation Insurance on above pilot(s)Has applicant had any aircraft/aviation losses/claims? Yes No Do all pilots have current Biennial Flight Review and Current Medical Certificate? Yes No Has any insurer canceled, declined or refused to renew any aviation insurance? Yes No Have you ever been convicted of a felony? Yes No As pilot, any citations for FAR violations or license limitations? Yes No Any physical impairments or limitations or waivers on Medical Certificate? Yes No If you decide to buy insurance, when should it become effective?When should insurance become effective? Same date as expiration above Other Insurance ServicesWe are able to provide additional discounts by quoting your auto, home and any other personal lines together. Please select the insurance services below that you would like a quote on.Other Insurance Services Personal Insurance: Auto, Home, Umbrella Life Insurance Financial Services: Individual or Group Health, Life Insurance, Retirement Solutions, Disability
