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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
Not Hangered
Hangered
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
Select one
Private
Commercial
ATP
Select one
Private
Commercial
ATP
Select one
Private
Commercial
ATP
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.
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