Avaition Quotation Form

Not all fields are required, but the more information you provide us, the easier and quicker we will be able to help you.

* Indicates required fields

Type of Entity	-- Corporation Holding Company LLC Individual Partnership	Registered Owner's Name*
Address*
City*		State*	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip*
Home Phone*		Business Phone
Fax		E-mail
Current Insurance Co.*     Exp. Date*

Aircraft Information
Year*		Make*
Model*		N#*
Type*	-- Land Sea Amphibious	Total Seats*
Insured Value*		Modifications
Engine HP*		Leinholder*
Amount $*

Liability
Limits of Liability*	-- 500,000/Occurrence limited to 100,000/Passenger 1,000,000/Occurrence limited to 100,000/Passenger 1,000,000/Occurrence with no Passenger Limitation Other
Medical Payments*	-- 0 500 1000 2000 2500 3000 5000

Aircraft Based
Airport Name*		City*
State/Province*		Airport ID*
Location Type*	-- Hangared Tied

Aircraft Use

Pleasure & Business Industrial Aid Instructional & Rental Other

Pilot #1 Information
Name		Occupation
Date of Birth
Ratings	Student Private Commercial ATP Instrument CFI MEI Single Engine Multi Engine Rotary Wing Jet Sea Plane Other

Pilot #1 Logged Hours
Total		Total PIC
Single Engine		Retract Gear
Multi Engine		Turbine
Tail Wheel		Rotary Wing
Jet		In Make/Model
Last 90 Days		Waivers
Last 12 Months
Have you ever had a DWI or DUI?* -- Yes No Accidents, Losses or Violations* -- Yes No If Yes please describe Annual Proficiency Training?* -- Yes No If Yes please describe

Pilot #2 Information
Name		Occupation
Date of Birth
Ratings	Student Private Commercial ATP Instrument CFI MEI Single Engine Multi Engine Rotary Wing Jet Sea Plane Other

Pilot #2 Logged Hours
Total		Total PIC
Single Engine		Retract Gear
Multi Engine		Turbine
Tail Wheel		Rotary Wing
Jet		In Make/Model
Last 90 Days		Waivers
Last 12 Months
Have you ever had a DWI or DUI?* -- Yes No Accidents, Losses or Violations* -- Yes No If Yes please describe Annual Proficiency Training?* -- Yes No If Yes please describe

Pilot #3 Information
Name		Occupation
Date of Birth
Ratings	Student Private Commercial ATP Instrument CFI MEI Single Engine Multi Engine Rotary Wing Jet Sea Plane Other

Pilot #3 Logged Hours
Total		Total PIC
Single Engine		Retract Gear
Multi Engine		Turbine
Tail Wheel		Rotary Wing
Jet		In Make/Model
Last 90 Days		Waivers
Last 12 Months
Have you ever had a DWI or DUI?* -- Yes No Accidents, Losses or Violations* -- Yes No If Yes please describe Annual Proficiency Training?* -- Yes No If Yes please describe

Please use the space below for any remarks you have.

139 Simsbury Rd     P.O. Box 1622     Avon, CT 06001     Phone: 1-800-932-4120     Fax: (860)-677-0438
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