Fill out the form below to get a FREE, quick insurance quote from the aviation insurance experts!

Please Direct my quote request to:

Coley Christian Aviation Insurance, Inc. -

Avemco Insurance Agency, Inc. -

Please direct my request to both companies -

Section A – Owner Information
Contact Name:   (Required)
Occupation:  
Address:   (Required)
 City:   (Required)
 State:    (Required)
Zip Code:    (Required)

E-mail

(Required)

Daytime Phone :  (Required)
Alternate Phone :  
Fax Number:   
Daytime Contact:  
Aircraft Use
AOPA Number:  
EAA Number:  

Section B – Aircraft Information

Aircraft Make/ Model:

   (Required)

Year:

 N - Number

Number of Seats:

 (Required)

Experimental/Amateur Built?::

 (Required)
Aircraft Base & Location
(City, State):		 (Required)

Is Aircraft Hangared:

 (Required)

Airport Name/ID

 (Required)

Section C – Pilot Information

First Name: (Required)
Last Name:  (Required)
Age: (Required)
Type of License:
Ratings:
Logged Flight Time:
Total Hours (All Aircraft): (Required)
Retractable Gear Hours
Multi-Engine Hours:
Turboprop Hours
Jet Hours:
Tailwheel Hours:
Make & Model Hours for aircraft in Section B: (Required)
Hours Last 12 Months: (Required)
Hours Last 90 Days: (Required)
Owner Flown or Professional Pilot?:
Will Aircraft be used commercially:
 

Any additional certificates, ratings, or recurrent training in the last 12 months?:

 Yes   No (Required)

(If "yes," must provide details, to include type & amount of hours, in the "Additional Information" box at the end of this form.)

Current Medical:

 Yes   No (Required)

Current Flight Review:

 Yes   No (Required)

Accidents/Incidents/
Suspensions/Claims:

 Yes   No (Required)

DUI/DWI:

 Yes   No (Required)

(If "yes," must provide details in the "Additional Information" box at the end of this form.)

Section D –  Coverage Information

Registered Owner:   (Required)

Current Insurer:

Exp:

If new, expected acquisition date:


Liability Limits Desired – 
 

Aircraft Damage (Hull) Coverage:

  $

 

(Current value of aircraft plus equip.)
 
Medical Payments (Optional)

Please use this space for any additional questions or comments. Be sure to include any details regarding accidents or incidents that any of the pilots may have had. Optional Information: If there are more than 2 pilots, please provide the additional pilot information as requested above. If the aircraft is owned by a corporation, please provide the name, address and purpose of the corporation.

Thank you for your time! Please check the above information for accuracy, and click on Submit for Quote!

NOTE: We cannot cancel, bind or amend coverage by this form request.