FALCON INSURANCE AGENCY - QUOTE REQUEST
Fill out the information and fax to (830) 792-1144 or mail to:

Falcon Insurance Agency Inc.
P.O. Box 291388
Kerrville, TX 78029

Please note we cannot accept binders or policy changes by email, only by phone during normal working hours.

ASSOCIATION INFORMATION

Are you a member of any of the following Aviation Associations?
ABS CPA EAA MAPA PPA SPA
None
PERSONAL INFORMATION
EAA Member Number
If applicable
Registered Owner
Contact Name
Address
City
State
Zip
Email
Work Phone
Home Phone
Fax
Occupation
*Current Policy Period
*required information -- if "New Purchase" or "None" please indicate
*Current Insurance Company
*required information -- if "New Purchase" or "None" please indicate
 
AIRCRAFT INFORMATION
 
Description of Aircraft Use
Type, Year and Model
If exprimental, provide Engine Make and Model
Airport Location
Hangared or Tied? (   Hangared,   Tied   )
Aircraft FAA Number
Total Seats
Agreed Hull Value
(Including all attached
equipment, i.e. floats)
Limits of Liability
*Is aircraft a Seaplane?
 (   Yes,   No   )
*Is aircraft based in Alaska?
*If yes, you will be asked to provide some additional information below necessary to process your quote.		 (   Yes,   No   )
 
Lienholder Name		  
Lienholder Address
City
State
Zip
Fax
Lien Amount
PILOT INFORMATION
*If aircraft is retractable gear, multi-engine, tailwheel, turbo-prop, jet powered, or rotorwing, please specify total logged hours for each category.

1. Pilot(s) Name
Age Certificate Ratings Total Hours Total Hours
Last 30 Days
(Please circle one)
-ATP
-Commercial
-Private
-Student
-Recreational		 Instrument
Helicopter
CFI
Single Engine Land
Multi Engine Land
Single Engine Sea
Multi Engine Sea
Glider
BFR Date Medical Date Make & Model hours
RG hrs ME hrs TW hrs Turbo Prop hrs Jet hrs RW hrs
   RG=Retractable Gear ME=Muti-Engine TW=Tailwheel RW=Rotorwing
 
2. Pilot(s) Name
Age Certificate Ratings Total Hours Total Hours
Last 30 Days
(Please circle one)
-ATP
-Commercial
-Private
-Student
-Recreational		 Instrument
Helicopter
CFI
Single Engine Land
Multi Engine Land
Single Engine Sea
Multi Engine Sea
Glider
BFR Date Medical Date Make & Model hours
RG hrs ME hrs TW hrs Turbo Prop hrs Jet hrs RW hrs
   RG=Retractable Gear ME=Muti-Engine TW=Tailwheel RW=Rotorwing
 
Please list flight schools, recurrency and type specific training.
 
Please list any losses, waivers, violations, cancellations or DWI's.
 
 
SEAPLANE AIRCRAFT INFORMATION
(Complete only if aircraft is a seaplane and/or based in Alaska)
 
Make & Model of Floats
Value of Floats
Dates Aircraft will be on Floats
Make & Model of Skis
Dates Aircraft will be on Skis
Dates Aircraft will be Laid-Up for Winter
SPA Member No.
 
PILOT INFORMATION
Pilot 1:
Please provide total logged hours for each category.
Last 12 Months
Last 90 Days
Single Engine Sea
Multi Engine Sea
Amphibian
Alaska Time (if applicable)
Hours in Make & Model: Land
Hours in Make & Model: Sea
 
Have you completed recurrent training? (   Yes,   No   )
If yes, when did you complete the training?
How much Dual Flight Instruction was logged?
 
Have you completed Sea Wings Program? (   Yes,   No   )
If yes, when did you complete the program?
 
Pilot 2:
Please provide total logged hours for each category.
Last 12 Months
Last 90 Days
Single Engine Sea
Multi Engine Sea
Amphibian
Alaska Time (if applicable)
Hours in Make & Model: Land
Hours in Make & Model: Sea
 
Have you completed recurrent training? (   Yes,   No   )
If yes, when did you complete the training?
How much Dual Flight Instruction was logged?
 
Have you completed Sea Wings Program? (   Yes,   No   )
If yes, when did you complete the program?