Aviation Products Liability Insurance Application
Applicant and Business Information
Applicant/Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Website Address
Form of Business
*
Corporation
Partnership
Other (Describe)
Subsidiary Companies, Divisions, or Other Entities
Have any subsidiary companies, divisions, or other entities been acquired or divested within the last ten years?
*
Yes
No
If yes, provide an explanation listing the entities and indicate whether liability for past production is retained
Policy Period and Liability Limits
Policy Effective Date Requested
*
-
Month
-
Day
Year
Date
Liability Limits Desired
Rows
Each Occurrence
Aggregate
Bodily Injury and Property Damage Products Liability
Grounding Liability
Premises Bodily Injury and Property Damage
Combined Annual Aggregate limit
Aviation Products and Manufacturing Profile
Describe all aviation products, including parts or raw materials
*
Describe the final components or systems your products are part of, and how your products function and are used
*
Are the products designed by your organization or manufactured to buyer specifications?
*
List all aircraft models your products are a part of
How many years has the applicant manufactured aviation products?
*
Has the applicant recalled or been ordered to recall any aviation products during the last five years?
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Yes
No
Are any products subject to an Airworthiness Directive?
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Yes
No
Has the applicant issued any service bulletins relating to aviation products during the last five years?
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Yes
No
If yes to any of the three questions above, provide details
Has the applicant discontinued manufacturing any aviation product?
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Yes
No
If yes, describe the discontinued product, date discontinued, total units produced, and past sales
Does the applicant lease aviation or other products to others?
*
Yes
No
Upload the leasing contract, if applicable
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Does the applicant own, lease, or operate any aircraft?
*
Yes
No
Is there known exposure for non-owned aircraft?
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Yes
No
Has the applicant installed or removed any products from aircraft?
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Yes
No
Is a certified management system in place?
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Yes
No
If yes, describe the certified management system
Describe the potential hazards of each aircraft product, including whether it is flammable, explosive, corrosive, poisonous, or toxic, and its chemical state
*
Have you entered into any agreements assuming liability of others?
*
Yes
No
If so, please upload the agreements here:
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Product Oversight Roles
Who inspects the product?
*
Applicant
Customer
Government
Contractor
Who instructs users?
*
Applicant
Customer
Government
Contractor
Who warns users?
*
Applicant
Customer
Government
Contractor
Who prepares operating and maintenance manuals?
*
Applicant
Customer
Government
Contractor
Sales by Product Category and Major Customers
Aviation Sales Receipts
*
Rows
Prior Year
Current Year
Next Year (Estimated)
Fixed Wing Airframes, Engines, Propellors, and Components
Rotor Wing Airframes, Engines, Rotors and Components
Unmanned Aerial Vehicles/Parts
Other Non-Military Aviation Products
Military Airframes, Engines, Propellors, and Components
Missiles and Missile Components
Other Military Aviation Products
Spacecraft Components
Total Prior Year Sales
Total Current Year Sales
Total Next Year Sales
Major Customer Sales
*
Rows
Customer
% of Sales
Major Customer 1
Major Customer 2
Major Customer 3
Major Customer 4
Insurance History and Loss History
Has any insurer cancelled, declined, or refused to renew aviation products liability insurance?
*
Yes
No
Has the applicant had any aviation products claims, lawsuits, or losses?
*
Yes
No
If yes to cancellation, nonrenewal, claims, lawsuits, or losses, provide details
Name of last or current aviation products or general liability insurer
Expiration date of aviation products or general liability policy
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Month
-
Day
Year
Date
Number of years insured with this liability insurer
Liability limit of last or current general liability policy
Fraud Warnings
Signatures
I certify that the above information is true to the best of my knowledge
*
Yes
No
Applicant Signature
*
Applicant Signature Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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