Aviation Professional Liability Application
Business Name
*
Contact Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Website
Describe Business/Operation of Applicant
*
How long has the applicant been in business?
*
Is the applicant engaged in any business or profession other than the above?
*
Yes
No
If yes, describe
Gross Revenues from Professional Services of Applicant
*
Rows
US
International
Total
Previous Year
Current Year
Next Year (Estimated)
Percentage of Revenue for each Professional Service Performed:
*
Rows
Professional Service
% Revenue
1
2
3
4
5
List your main clients/customers:
*
Do you use a written contract or agreement describing the services to be provided to the client?
*
Yes
No
If yes, please provide a sample agreement
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If no, how is the agreement with the client documented?
Are there any hold harmless agreements, warrant provisions, or gaurantees in place?
*
Yes
No
Do any of your employees conduct test flights, flight checks, or ferry flights in 3rd party aircraft?
*
Yes
No
If yes, how many flight hours per year?
Describe your loss prevention measures
Describe risk or quality management procedures in use such as ISO 31000, ISO 9002 or similar:
Have you ever had professional liability insurance?
*
Yes
No
Have you had a professional liability claim within the last 5 years?
*
Yes
No
If yes, describe
Fraud Statements
Signature
Submit
Should be Empty: