Aircraft Maintenance General Liability Application

Aircraft Maintenance General Liability Application

Schrager Hampson Aviation Insurance Group
Applicant Information
Applicant Contact Name

First NameLast Name
Business Name
Business Website (if applicable)
Business is:

Other
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address (Non-Residential Address Preferred)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requested Effective Date

MonthDayYear
Date
Airport
Home Airport Base Identifier
Type "Mobile" if there is no home airport base**
Airport Name
Airport State
Operations of Applicant
Business of Applicant:
Describe your operations
Identify All Operations Performed By Applicant

Other
Estimated Annual Receipts by Category:
Total Estimated Annual Receipts:
Prior 12 Months Receipts (if applicable):
Type of Aircraft Worked on:
Average Value of Aircraft Worked on:
Are aircraft of others taxied, towed or moved by Applicant?
Is there fueling on Airport Premises?
Is Fueling Performed by Applicant?
If yes to fueling, Annual Gallonage:
Piston Fuel Sales ($)
Jet Fuel Sales ($)
Does Insured Own Vehicles, Mobile Equipment, or Aircraft?
If Yes, Indicate Number and Type of Vehicle(s)
Has applicant entered into any written agreements assuming the liability of others, such as under a lease of premises, fuel supplier contract or equipment lease?
"YES", please attach copies of all such agreements.

Cancelof
Limits of Liability
Per Occurrence Limit Requested
Aggregate Limit Requested
Products and Completed Operations Limit Requested Per Occurrence
Products and Completed Operations Limit Requested Per Aggregate
Personal Injury and Advertising
Fire Damage Legal Liability Requested (Also known as Damage to Premises Rented)
Medical Expense Limit Per Person/Occurrence
Hangarkeepers Limit Per Aircraft
Hangarkeepers Limit Per Occurrence
Loss History
Has applicant had any claims occurring during the last 5 years other than those associated to Workers Compensation?
If yes, please describe each claim including date of loss, description, and total claim payout
I, the undersigned, hereby declare and warrant that all of the information and answers given in this Application are true and complete in every respect to the best of my knowledge and belief, and that no material information has been withheld or suppressed. I agree that the information given in this Application shall form the basis for acceptance by the insurance company issuing any policy in reliance hereon.
Signature
Date of Signing

MonthDayYear
Date
Please verify that you are human
Should be Empty:

Aircraft Maintenance General Liability Application

Applicant Information

Airport

Operations of Applicant

Limits of Liability

Loss History