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Glider Flying Club Aircraft Insurance Needs.

Date:
Policyholder's Name:
Address:
City:		State:
Zip:
Day Phone:		Fax:
Eve Phone:		E-mail:
Name of Person to Contact:
Is the club a member of the Soaring Society of America?	Yes	No
Occupation/Nature of business:
Present Insurance Company (not agent)
Policy expiration date:

Airport Name:
Airport City:		State:

Aircraft Schedule
(Applicable to Gliders and Tow Planes)
FAA N#	Year Make & Model	Glider Value	Trailer Value

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