Aircraft Quote

Call 1-877-386-2601

Special Deals on
Auto & Homeowners
Insurance For Pilots
By Balliet

Aircraft Insurance Request Form

Required Fields
Owner Information

First Name		Last Name
Address		City
State		Zip Code
Phone #:		EMail Address
Occupation		Desired Effective Date
Aircraft Use		If Club	# of members
Expiration	Date	A.O.P.A. Member

Aircraft Information

Aircraft Make/Model	Registration Number
Year of Manufacture	Engine Horsepower
Number of Seats	Aircraft Hangared ?	Yes No
Aircraft Base	FAA Airport Identifier

Pilot 1	Pilot Information	Pilot 2
First Name
Last Name
Date of Birth
Age of Pilot
Type of License
Ratings
Instrument Rated	Yes No	Yes No
Pilot 1	Logged Flight Time	Pilot 2
Total (All Aircraft)	Hours
Tailwheel	Hours
Retractable Gear	Hours
Multi-Engine	Hours
Make & Model	Hours
Current Flight Review	Yes No	Yes No
Accidents/Incidents Suspensions/Claims	Yes No	Yes No

Coverage Information

Liability Limits – Select One
Bodily Injury	Property Damage	Per Occurrence
$50,000	$500,000	$500,000
$100,000	$500,000	$500,000
$100,000	$1,000,000	$1,000,000

Aircraft Damage – Hull Coverage
Aircraft Insured Value:
Choose An Option:

Medical Payments – Select One

None

$1,000

$2,500

$3,000

Additional Information:

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By Clicking Submit below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

BALLIET INSURANCE AGENCY, INC.
Telephone: 1-877-386-2601
FAX: 1-570-386-4385
Postal address: 1403 Blakeslee Blvd. Lehighton, PA., 18235
Electronic mail: General Information: johntag@ptd.net