MacKenzie Aviation - Online Quote

Welcome to MacKenzie Aviations' Online Quote Page. We also have a non-owned quote form and for those who may not want to fill out the information and send it via the internet, we offer downloadable forms and other options found on the offline quote page. You can renew an existing policy with this form or you can fill out our policy form to request information or changes.

Please fill out the following information completely. Choose the limits and coverage to meet your needs and then submit for a quote and we'll handle the rest! You may contact us to customize any policy to suit your specific needs!

This quote request form is for the following:

Quote for new policy Renewal on existing policy

Policy #

Personal Information: (*) Required information. Any fields omitted may delay quote

* Full Name:
* Street Address:			Apt. No.
* City:			* State
* Zip/Postal Code:	-
Work Phone:		Fax
Home Phone:		Fax
E-mail:
* Present Ins. Company:
* Expiration Date:	-- m/d/y
* Expiration Premium:	$

* Preferred method of contact: If 'Other', specify:

Airport and Aircraft Storage Information:

*Name of Airport: *Runway Length (ft.):
Location of Airport (City): State:
*Runway surface: *How is the aircraft stored:

Aircraft and Use Information:

*Liability Amounts:
	Each Occurrence:	Each Passenger:
	Medical Pay:	Hull: $ (Craft Value)

Aircraft Uses: (Choose all that Apply)*
	Pleasure & Business	Instruction & Rental	Aerial Photography
	Banner Towing	Charter	Flying Club
	Patrol Flights	Crop Dusting	Other

Aircraft Information:
*1. N#:	Make:	Model:	Horsepower:	Year:
Lienholder:		Amount: $	Value: $	Seats:

2. N#:	Make:	Model:	Horsepower:	Year:
Lienholder:		Amount: $	Value: $	Seats:

NOTE: Need to add more aircraft?

Pilot Log & Record Information:

*Pilot #1:
Name: Date of Birth: -- m/d/y
Occupation: Medical Due Date: -- BFR Due Date: --

License and Ratings: (Choose All That Apply)
	License	Ratings/Certificates	Log	Hours
	Private	IFR	*Total Time:
	Commercial	Single Engine Land	Retractable Gear:
	Student	Multi-Engine Land	Multi-Engine:
	ATP	Single Engine Sea	Tail Wheel:
		Helicopter	Make/Model:
		Glider	Last 90 Days:
		CFI	Pressurized:
		CFII	Turbo-Prop:
		CFMEI

If applicable, advise flight school attended or any additional training or schooling.

Started: -- Ended: -- (m/d/y)

Accidents Violations Physical Defects Waivers DUIs Felonies

For each box checked, please indicate date and a brief explanation of the incident:

Pilot #2: (Need to add more pilots?)
Name: Date of Birth: -- (m/d/y)
Occupation: Medical Due Date: -- BFR Due Date: --

License and Ratings: (Choose All That Apply)
	License	Ratings/Certificates	Log	Hours
	Private	IFR	Total Time:
	Commercial	Single Engine Land	Retractable Gear:
	Student	Multi-Engine Land	Multi-Engine:
	ATP	Single Engine Sea	Tail Wheel:
		Helicopter	Make/Model:
		Glider	Last 90 Days:
		CFI	Pressurized:
		CFII	Turbo-Prop:
		CFMEI

If applicable, advise flight school attended or any additional training or schooling.

Started: -- Ended: -- (m/d/y)

Accidents Violations Physical Defects Waivers DUIs Felonies

For each box checked, please indicate date and a brief explanation of the incident:

Any additional information or comments may be made here:

-- Please take a moment to review all of the information. Any missing or incorrect information could cause delays in quote and process time. Thank you. --

If you need to add more aircraft or pilot information:
Once this form is filled out and successfully submitted, you will be sent to a Confirmation Page. There will be a link there to another form where you can supply the additional information. Sorry if this causes you any inconvenience.
Return to Pilot Log

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