Quote 1

Fill Out Form For Someone To Contact You To Discuss
Personal, Pleasure and Competition Glider Insurance Needs.

Date:
Policyholder's Name:
Address:
City:		State: Zip:
Day Phone:		Fax:
Eve Phone:		E-mail:
Name of Person to Contact:
Are you a member of the Soaring Society of America?		Yes No
If yes, please provide your SSA membership #:
Occupation/Nature of business:
Are you a member of the Aircraft Owners and Pilots Association (AOPA):		Yes No
If yes, please provide your AOPA membership#:
Are you just purchasing this aircraft?		Yes No
Present Insurance Company (not agent)
Policy expiration date:

Pilot 1
Pilots Name	Age
Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG):
Total Glider Flights
Total flights in glider with a glide ratio of 35-1 or better
Total Flights in each Make & Model to be Insured 1: 2: 3:
Any physical disabilities that might impact the pilots ability to operate the glider?	Yes	No
If yes, please describe:

Pilot 2
Pilots Name	Age
Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG):
Total Glider Flights
Total flights in glider with a glide ratio of 35-1 or better
Total Flights in each Make & Model to be Insured 1: 2: 3:
Any physical disabilities that might impact the pilots ability to operate the glider?	Yes	No
If yes, please describe:

Pilot 3
Pilots Name	Age
Glider Certificates/Ratings (i.e Student, Private, Commerical, CFIG):
Total Glider Flights
Total flights in glider with a glide ratio of 35-1 or better
Total Flights in each Make & Model to be Insured 1: 2: 3:
Any physical disabilities that might impact the pilots ability to operate the glider?	Yes	No
If yes, please describe:

If the glider(s) are single seaters, do you wish a quote providing the ability to loan it out to others?	Yes	No
Pilot Loss History
Has any of the above pilots had any FAR Violation, aviation loss or claim, been cited for reckless or drunk driving?	Yes	No
If yes, please provide names, dates, and details below. Comments Please list any questions or comments below:

Thank you for taking the time to complete this form.

Costello Insurance
Associates, Inc.
Tel: 800.528.6483
Tel: 480.968.7746
Fax: 480.967.3828
insure@aviationi.com