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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

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.

 
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