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Please complete the questionnaire below for a personalized quote.

If you prefer to speak with someone in our offices, please feel free to contact us at: 781-274-0303

Policy Type

Type

Company Name

First Name

Last Name

Pilot Name

Pilot Age

Pilot Ratings

Other Pilot Ratings

Pilot Certificate

Are There Any Physical Impairments Or Limitations Or Waivers On The Medical Certificate?

Yes No

Does this include vision correction?

Yes No

Does this include color blindness?

Yes No

Does this include any other condition?

Yes No

Please Explain

Telephone

Email

Address

City

State

Zip Code

Desired Effective Date

Aircraft Make

Model

Aircraft Manufacture Year

Tail #

Airport Code

How Is The Aircraft Stored

Hangared Moored Tied Unknown

Crew Seats

Passenger Seats

Use of Aircraft

Hull Value

Liability Limit

Total Tailwheel Hours

Total Retractable Gear Hours

Total Multiengine Hours

Pilot's Total Hours Logged In The Last 12 Months

Total Hours Logged In Insured Make and Model

Total Hours Logged In Insured Make and Model In The Last 12 Months

Total Hours

Any Prior FAA Violations?

Yes No

Please Explain

Any Insurance Claims in the past?

Yes No

Please Explain

Last BFR

Current in Medical?

Yes No

Do you need a quote multiple aircraft?

Yes No

Do you need a quote multiple pilots?

Yes No

Has this pilot ever had any aviation claims, incidents, accidents, FAR violations DUI's, felony convictions, or been under indictment?

Yes No

Please explain

Other than reported pilot losses, has this Insured made any aircraft or aviation insurance claims (Last 5 Years)?

Yes No

Please Explain

Other Claim Date

Will the aircraft be operated in Hawaii or Alaska

Yes No

Please explain

Will the aircraft be operated at other than paved public airports?

Yes No

Where and how often?

Will any insured aircraft knowingly be operated outside the United States?

Yes No

Please explain

Is any scheduled aircraft part of a Flying Club or used for any purpose other than Pleasure and Business or Industrial Aid

Yes No

Please explain

Does the aircraft have other than a standard airworthiness certificate?

Yes No

Please explain

Has the applicant had aircraft hull or liability insurance cancelled by an insurance company or underwriter?

Yes No

Any Additional Comments/Notes