Costello Insurance Associates Aviation Insurance

 Costello Insurance
 Associates, Inc.
 Tel: 800.528.6483
 Tel: 480.968.7746
 Fax: 480.967.3828
 insure@aviationi.com

Aircraft above clouds
Free Quote for Aviation Insurance

Fill Out Form For Someone To Contact You To Discuss
Corporate Aircraft Insurance Needs.

Policyholder's Information  
Registered Owner(s)
Occupation of each Owner
Street Address
City State      Zip  

Contact Information for Person Handling Insurance
First Name Last Name   
Work Phone Home Phone  
Email Fax  

How did you hear about us?

Is this a new purchase? If not provide current insurance company data below.
Present Insurance Company
Policy Expiration Date
AOPA Number Member Name

Aircraft Data
N#?
Year?
Make?
Model?
Total Seats?
Desired Insured Value? $
Based at What Airport?
Airport's Identifier?
Stored

Use

Industrial Aid (Pro Pilot Flown Only)
Pleasure and Non-Commercial Business (Non Pro Flown)
Instruction and Rental for Hire
Charter Commercial
Instruction/Rental/Charter
Other:

Is or will there be a lienholder?
Amount of Loan?


Pilot Information
  Pilot 1 Pilot 2 Pilot 3
First Name
Last Name
Age
License Type

Does pilot have a Type Rating for this aircraft?

Yes
No
Not Required

Yes
No
Not Required

Yes
No
Not Required

Ratings (Please choose all that apply)

IFR
SEA
Multi-Engine
Rotor
CFI


IFR
SEA
Multi-Engine
Rotor
CFI


IFR
SEA
Multi-Engine
Rotor
CFI

Name of Factory School Completed for this aircraft?

Date last attended?







Factory School
      Not Required







Factory School
      Not Required







Factory School
      Not Required


Logged Pilot Hours
  Pilot 1 Pilot 2 Pilot 3
Total Logged Hours

Total hours in this model

Retractable Gear Time
(if applicable)

Multi-Engine Time
(if applicable)

Tailwheel Time
(if applicable)

Turboprop Time
(if applicable)

Pure Jet Time
(if applicable)

Rotor Time
(if applicable)

Seaplane Time
(if applicable)

Other

Hours flown in all aircraft in last 12 Months


Liability Limits Requested




All pilots above have a valid and effective pilot certificate?

Yes No

For all pilots, please list any aviation accidents, waivers, violations, losses, incidents, DUI or DWI’s below: Give dates and details. If none, say none in the box below.



Any flights out of the United States anticipated? If yes, please list countries below.



Comments
Please list any questions or comments below:


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