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*Total Hours Last 12 Months*Total Make and Model Hours Last 12 Months*BFR Date Medical Date Make and Model Hrs*Total Logged Hours for the following:Retractable Gear Hrs*Multi-Engine Hrs*Tail Wheel Hrs*Gyro (Turbo Prop) Hrs*Jet Hrs*Rotorwing Hrs*Seaplane HoursLast 12 Months Hrs*Last 3 Months Hrs*Single Engine Sea Hrs*Multi Engine Sea Hrs*Amphibian Hrs*Alaska Time Hrs*Make/Model :: Land Hrs*Make/Model :: Sea Hrs*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*Total Hours Last 12 months*Total Make and Model Hours Last 12 Months*BFR Date Medical Date Make and Model Hours*Total Logged Hours for the Following:Retractable Gear Hrs*Multi-Engine Hrs*Tail Wheel Hrs*Turbo Prop Hrs*Jet Hrs*Rotorwing Hrs*Seaplane HoursLast 12 Months Hrs*Last 3 Months Hrs*Single Engine Sea Hrs*Multi Engine Sea Hrs*Amphibian Hrs*Alaska Time Hrs*Make/Model :: Land Hrs*Make/Model :: Sea Hrs*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*Total Hours Last 12 months*Total Make and Model Hours Last 12 Months*BFR Date Medical Date Make and Model Hours*Total Logged Hours for the Following:Retractable Gear Hrs*Multi-Engine Hrs*Tail Wheel Hrs*Turbo Prop Hrs*Jet Hrs*Rotorwing Hrs*Seaplane HoursLast 12 Months Hrs*Last 3 Months Hrs*Single Engine Sea Hrs*Multi Engine Sea Hrs*Amphibian Hrs*Alaska Time Hrs*Make/Model :: Land Hrs*Make/Model :: Sea Hrs*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:CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.
