Fill Out Form For Someone To Contact You To Discuss
Corporate Aircraft Insurance Needs.
Occupation of each Owner
Contact Information for Person Handling Insurance
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
Desired Insured Value?
Based at What Airport?
Industrial Aid (Pro Pilot Flown Only)
Pleasure and Non-Commercial Business (Non Pro Flown)
Instruction and Rental for Hire
Is or will there be a lienholder?
Amount of Loan?
Does pilot have a Type Rating for this aircraft?
Ratings (Please choose all that apply)
Name of Factory School Completed for this aircraft?
Date last attended?
Logged Pilot Hours
Total Logged Hours
Total hours in this model
Retractable Gear Time
Pure Jet Time
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?
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.
Please list any questions or comments below:
Thank you for taking the time to complete this form.
Copyright 2005-2016 Costello Insurance Associates, Inc.