Premier Class Insurance Services, Inc.
First Tower Insurance

 

For a prompt, free quote, please complete our online application form.
If you would like to have our agent contact you directly for this information,
please include your name and phone number in lieu of completing this form.

PERSONAL PLEASURE &
BUSINESS FIXED-WING AIRCRAFT
INSURANCE ONLINE QUOTATION FORM


 

Name of Applicant(s)

Applicant's Address:

City:   State:   Zip:

Home Ph#:     Work Ph#:      Fax Ph#:

Email Address:

Business or Occupation of Applicant:

Coverage Effective from:     Until: 12:01 Standard Time at above address

Applicant is the sole owner of the aircraft, other than:

Describe other aircraft owned by applicant (s):

Exact use of aircraft:

Has any insurance company cancelled or refused to renew your aircraft insurance?  No   Yes

Please explain:

Name of current insurance company:

Current Policy Number:

Please list any losses below:

 

AIRCRAFT

Operations other than Paved Public Airports:

Airstrip Length Ft.     Airstrip Width Ft.     Landing  Surface     Obstructions

Year/Make/Model N#    

Total Seats:     

Annual Hours Flown:         

Date of Last Annual:             

Engine Make/Model & Hours since overhaul:
Input information into text areas

       

Describe "Airworthiness" Certificate Other than Standard:

       

Describe Aircraft Modification or Unrepaired Damage:

       

Airport Name/City/State: 
Input information and make a selection

COVERAGE

Insured Value: 
Input information and make a selection

$    $     $

Deductibles: 

Not-in-Motion: $    $    $

In-Motion:        $    $    $

Lien Holder & Address:       

Lien Amount:
Input information and make a selection

  $     

  $       

  $   

Combined Single Limit of Liability (Bodily injury and property damage):

$ Ea. Occurrence     Excluding Passengers    Including Passengers  $ Ea. Passenger

Medical Payments:  $Ea. Passenger   $Ea. Passenger $Ea. Passenger

Total Premium:  $       $        $

 

Pilot Qualifications #1:

Name:       Age:  

Pilot Certificates and Ratings:

Student   PVT   CML    AMEL   Instrum.   AIP         Other:

Medical Certificate:      Expiration Date    Class

Logged Pilot in Command Hours:

Date of last B.F.R.   Total Time    Total R/G    Total M/E

Total Tail Wheel       Other  

Total Hours in Aircraft Model to be Insured: 

Total Hours in All Aircraft Past 90 Days:       12 Months

 

 

Pilot Qualifications #2:

Name:       Age:  

Pilot Certificates and Ratings:

Student   PVT   CML    AMEL   Instrum.   AIP         Other:

Medical Certificate:      Expiration Date    Class

Logged Pilot in Command Hours:

Date of last B.F.R.   Total Time    Total R/G    Total M/E

Total Tail Wheel       Other  

Total Hours in Aircraft Model to be Insured: 

Total Hours in All Aircraft Past 90 Days:       12 Months

 

 

Pilot Qualifications #3:

Name:       Age:  

Pilot Certificates and Ratings:

Student   PVT   CML    AMEL   Instrum.   AIP         Other:

Medical Certificate:      Expiration Date    Class

Logged Pilot in Command Hours:

Date of last B.F.R.   Total Time    Total R/G    Total M/E

Total Tail Wheel       Other  

Total Hours in Aircraft Model to be Insured: 

Total Hours in All Aircraft Past 90 Days:       12 Months

 


PREMIER CLASS INSURANCE SERVICES, INC.
10002 Pioneer Blvd.   Suite 104
Santa Fe Springs, CA  90670

PHONE:   (562) 821-0321
TOLL FREE:   (866) 441-0321
FAX:   (562) 949-7146
E-mail:   info@firsttower.com

CA Lic. #: 0D08422