General Quote Request General Quote Form Step 1 of 8 - Personal Information 12% Personal InformationRegistered Owner*Contact Name*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Primary Phone*Alternative PhoneFaxOccupation*Do you currently have a policy?*NoYesNew PurchaseAssociation MembershipAre you a member of any of the following? (if none, leave blank)ABSCPAEAAMAPAPPASPAUSAAAre you a AOPA member? (if none, leave blank) AOPA Aircraft InformationIs this aircraft a Seaplane?*NoYesDoes your aircraft use skis during the year?*NoYesIs your aircraft laid-up (Stored) for a specific period during the year?*NoYes Memership InformationABS Member #:CPA Member #:EAA Member #:MAPA Member #:PPA Member #:SPA Member #:USAA Member #:AOPA Member #:Current Policy InformationCurrent Insurance Company:Current Policy Begin Date* Current Policy End Date* Specific Aircraft InformationSeaplane, Float and/or Stored information.Year, Make and Model of FloatsValue of FloatsSeparate from Hull ValueAircraft on Floats Begin Date Aircraft on Floats End Date Make and Model of SkisValue of SkisSeparate from Hull ValueAircraft on Skis Begin Date Aircraft on Skis End Date Aircraft laid-up (Stored) Begin Date Aircraft laid-up (Stored) End Date General Aircraft Use InformationAircraft UsePleasure & BusinessCommercial - Please ExplainDescription of Commercial Aircraft Use*Year/Make/Model*Gear Configuration* Tri-Gear Tail Wheel Retractable Provide Engine Make & ModelAirport ID or Name of Airport and Location*Runway LengthSurface MaterialHangared or Tied*HangaredTiedFAA Number*Total Seats*Agreed Hull Value*Limits of Liability-- Please Choose --$500,000 CSL / $100k per Passenger$1,000,000 CSL / $100k per Passenger$1,000,000 CSLOtherIf other Liability, please explainNumber of Pilots123Does your Aircraft have a lien*yesno Lien InformationLienholder Name*Lienholder Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Lienholder Phone*Lienholder Fax*Lien Amount* Pilot InformationPilot Name*Date of Birth (D.O.B)* Age*Certificates ATP Commercial Private Student Recreational Sport Ratings Instrument Helicopter CFI Single Engine Land Multi Engine Land Single Engine Sea Multi Engine Sea Glider Total Hours*Please enter a value greater than or equal to 0.Total Hours Last 12 Months*Please enter a value greater than or equal to 0.Total Make and Model Hours Last 12 Months*Please enter a value greater than or equal to 0.BFR Date Medical Date Make and Model Hrs*Please enter a value greater than or equal to 0.Total Logged Hours for the following:Retractable Gear Hrs*Please enter a value greater than or equal to 0.Multi-Engine Hrs*Please enter a value greater than or equal to 0.Tail Wheel Hrs*Please enter a value greater than or equal to 0.Glider Hrs*Please enter a value greater than or equal to 0.Gyro (Turbo Prop) Hrs*Please enter a value greater than or equal to 0.Jet Hrs*Please enter a value greater than or equal to 0.Rotorwing Hrs*Please enter a value greater than or equal to 0.Seaplane HoursLast 12 Months Hrs*Please enter a value greater than or equal to 0.Last 3 Months Hrs*Please enter a value greater than or equal to 0.Single Engine Sea Hrs*Please enter a value greater than or equal to 0.Multi Engine Sea Hrs*Please enter a value greater than or equal to 0.Amphibian Hrs*Please enter a value greater than or equal to 0.Alaska Time Hrs*Please enter a value greater than or equal to 0.Make/Model :: Land Hrs*Please enter a value greater than or equal to 0.Make/Model :: Sea Hrs*Please enter a value greater than or equal to 0.Additional Training InformationHave you completed recurrent trainingyesnoWhen did you complete the training How much dual flight instruction was loggedHave you completed the Sea Wings Program?yesnoWhen did you complete the program? Please list flight schools, re-currency and type of specific training:Please list any losses, waivers, violations, cancellations or DWI's: Pilot #2 InformationPilot Name*Date of Birth (D.O.B)* Age*Certificates ATP Commercial Private Student Recreational Sport Ratings Instrument Helicopter CFI Single Engine Land Multi Engine Land Single Engine Sea Multi Engine Sea Glider Total Hours*Please enter a value greater than or equal to 0.Total Hours Last 12 months*Please enter a value greater than or equal to 0.Total Make and Model Hours Last 12 Months*Please enter a value greater than or equal to 0.BFR Date Medical Date Make and Model Hours*Please enter a value greater than or equal to 0.Total Logged Hours for the Following:Retractable Gear Hrs*Please enter a value greater than or equal to 0.Multi-Engine Hrs*Please enter a value greater than or equal to 0.Tail Wheel Hrs*Please enter a value greater than or equal to 0.Glider Hrs*Please enter a value greater than or equal to 0.Turbo Prop Hrs*Please enter a value greater than or equal to 0.Jet Hrs*Please enter a value greater than or equal to 0.Rotorwing Hrs*Please enter a value greater than or equal to 0.Seaplane HoursLast 12 Months Hrs*Please enter a value greater than or equal to 0.Last 3 Months Hrs*Please enter a value greater than or equal to 0.Single Engine Sea Hrs*Please enter a value greater than or equal to 0.Multi Engine Sea Hrs*Please enter a value greater than or equal to 0.Amphibian Hrs*Please enter a value greater than or equal to 0.Alaska Time Hrs*Please enter a value greater than or equal to 0.Make/Model :: Land Hrs*Please enter a value greater than or equal to 0.Make/Model :: Sea Hrs*Please enter a value greater than or equal to 0.Additional Training InformationHave you completed recurrent trainingyesnoWhen did you complete the training How much dual flight instruction was loggedHave you completed the Sea Wings Program?yesnoWhen did you complete the program? Please list flight schools, re-currency and type of specific training:Please list any losses, waivers, violations, cancellations or DWI's: Pilot #3 InformationPilot Name*Date of Birth (D.O.B)* Age*Certificates ATP Commercial Private Student Recreational Sport Ratings Instrument Helicopter CFI Single Engine Land Multi Engine Land Single Engine Sea Multi Engine Sea Glider Total Hours*Please enter a value greater than or equal to 0.Total Hours Last 12 months*Please enter a value greater than or equal to 0.Total Make and Model Hours Last 12 Months*Please enter a value greater than or equal to 0.BFR Date Medical Date Make and Model Hours*Please enter a value greater than or equal to 0.Total Logged Hours for the Following:Retractable Gear Hrs*Please enter a value greater than or equal to 0.Multi-Engine Hrs*Please enter a value greater than or equal to 0.Tail Wheel Hrs*Please enter a value greater than or equal to 0.Glider Hrs*Please enter a value greater than or equal to 0.Turbo Prop Hrs*Please enter a value greater than or equal to 0.Jet Hrs*Please enter a value greater than or equal to 0.Rotorwing Hrs*Please enter a value greater than or equal to 0.Seaplane HoursLast 12 Months Hrs*Please enter a value greater than or equal to 0.Last 3 Months Hrs*Please enter a value greater than or equal to 0.Single Engine Sea Hrs*Please enter a value greater than or equal to 0.Multi Engine Sea Hrs*Please enter a value greater than or equal to 0.Amphibian Hrs*Please enter a value greater than or equal to 0.Alaska Time Hrs*Please enter a value greater than or equal to 0.Make/Model :: Land Hrs*Please enter a value greater than or equal to 0.Make/Model :: Sea Hrs*Please enter a value greater than or equal to 0.Additional Training InformationHave you completed recurrent trainingyesnoWhen did you complete the training How much dual flight instruction was loggedHave you completed the Sea Wings Program?yesnoWhen did you complete the program? Please list flight schools, re-currency and type of specific training:Please list any losses, waivers, violations, cancellations or DWI's:NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.
