Premier Services - The Insurance Experts

Aviation Insurance Application
(Quotes will be provided for Pennsylvania, New Jersey, New York, Maryland and Delaware)

*Pilot #1 Information*
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Age:
Occupation:
Ratings:
Total hours:
Past year hours:
Make and model hours:
Hours in retractable gear:
Hours in multi engine:
Date of last medical:
Date of last BFR:
*Pilot #2 Information*
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Age:
Occupation:
Ratings:
Total hours:
Past year hours:
Make and model hours:
Hours in retractable gear:
Hours in multi engine:
Date of last medical:
Date of last BFR:
*Aircraft Information*
Airplane use:
Based airport (town and state):
Is the aircraft:
N number:
Make:
Model:
Year:
Number of seats:
Gear:
Number of engines:
Engine hours:
Any claims (list date, details, amount paid):
Any lienholders:
*Coverages*
Current insurer:
Expiration date:
Premium paid:
Liability:
Hull coverage:
In motion deductible on hull:
Not-in-motion deductible on hull:
Medical payments:
Do you have quotations from other companies?	Yes No
Would you like to compare the best quote you received against our policy?	Yes No
Who is the insurance company?
What was the price quoted?
How did you hear about us?
Additional Comments: