Corporate Aircraft Insurance Quote

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

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

$1,000,000 Combined Single Limit including $100,000 per passenger. $1,000,000 Combined Single Limit with no passenger limitation. Other (please specify below):

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:

Thank you for taking the time to complete this form.

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