Untitled Document

CGA AVIATION INSURANCE QUOTE
We would like to provide you with a free, no-obligation quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Submitting Information

Business Name:
Contact Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	Fax:

General Information

Registered Owner Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Current Aviation Insurance Information

Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months 1 Year Other:

Aircraft Information

Aircraft
#1

Year

Make/Model:

Engine Type:

Horsepower:

# of seats:

Date Purchased

Purchase Price
$

Present Value
$

Aircraft Cat.
Exp.	Std.

Aircraft Hangared at:

Lienholder:

Additional Insured / Address

FAA Reg. #:

Aircraft
#2

Year

Make/Model:

Engine Type:

Horsepower:

# of seats:

Date Purchased

Purchase Price
$

Present Value
$

Aircraft Cat.
Exp.	Std.

Aircraft Hangared at:

Lienholder:

Additional Insured / Address

FAA Reg. #:

Aircraft
#3

Year

Make/Model:

Engine Type:

Horsepower:

# of seats:

Date Purchased

Purchase Price
$

Present Value
$

Aircraft Cat.
Exp.	Std.

Aircraft Hangared at:

Lienholder:

Additional Insured / Address

FAA Reg. #:

Pilots/Operators

#	Name	DOB	Ratings/ Certificates	Logged Hours
#	Name	DOB	Ratings/ Certificates	Tail Wheel	Retract. Gear	In Model	Last 12 months
1
2
3
#	Claims, incidents, FAA Medical Waivers, FAR Violations, DUI, Felony Convictions:					Occupation
1
2
3

Liability Limit For ALL Aircrafts
Bodily Injury	Property Damage	Per seat Medical

Hull Coverage For ALL Aircrafts
Coverage Type:	Amount Requested: $

Miscellaneous Information
Aircraft Use:	Business & Pleasure Business Pleasure Commercial
Passenger Charters:	Yes No	Crop Dusting:	Yes No
Flight Instructor:	Yes No	Aircraft Based:	Yes No
Aircraft Hangared:	Yes No	On Floats:	Yes No
Tied Down:	Yes No	Paved Runway:	Yes No
Airport Name:		Airport Location:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional operators, coverages, etc..., please enter them here.