Aviation Workers Compensation Supplemental Application
Applicant Name
*
Email Address
example@example.com
Effective Date
*
-
Month
-
Day
Year
Date
Description of Operations
*
Fleet Information:
Rows
Year
Make
Model
Total Seats
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Attach Fleet Schedule (If not enough space above):
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Airport Identifier
*
Airport Location
*
Name of Aviation Hull & Liability Insurance Company:
List total Pilots/Crew
Rows
Full Time
Part Time
Fixed Wing
Rotor Wing
Flight Attendants
# of Flight Crew
Rows
#
Max Flight Crew
Average Flight Crew
Contractors
Any leased or independant contractor employees?
*
Yes
No
If yes, how many?
Estimated 1099 Payroll:
Are Certificates of Insurance Required?
Yes
No
Operational Questions
Have pilots attended the aircraft manufacturer's approved initial training or recurrent training school for all aircraft being operated within the previous 12 months?
*
Yes
No
Any international exposure?
*
Yes
No
If so, where?
How often per year?
Average duration of layover
Do you engage in Part 91 Operations?
*
Yes
No
Do you engage in Part 135 Operations?
*
Yes
No
Describe any operations outside of Part 91 or Part 135:
Do you engage in any seaplane, float, ski, or bush operations or have any maritime exposure?
*
Yes
No
Any antique, experimental, ex-military, aerobatic, exhibition or racing aircraft exposure?
*
Yes
No
Any exterior cleaning, stripping, or spray painting operations?
*
Yes
No
Do employees perform test flights after maintenance or service of aircraft?
*
Yes
No
Do employees use personal vehicles in the course of employment?
*
Yes
No
Do you have any other Workers Compensation policies in force?
*
Yes
No
If so, list the insurance company, policy number, and effective date:
Are there Helicopter operations?
*
Yes
No
Do all helicopter pilots have an instrument rating?
Yes
No
What are the minimum requirements for helicopter pilots?
Are flight operations conducted at night?
Yes
No
Are night vision goggles used?
Yes
No
Are helicopters equipped with TAWS?
Yes
No
Are helicopters equipped with weather GPS?
Yes
No
Are helicopters equipped with satellite tracking devices?
Yes
No
Do you have safety certifications?
Yes
No
Are risk assessments conducted prior to each flight?
Yes
No
Are maintenance personnel required to have prior rotor wing experience?
Yes
No
Do all maintenance personnel attend initial and recurrent factory training?
Yes
No
Exposure to US Acts
Exposure to any of the following Acts?
*
Rows
Y/N
USL&H Act?
Defense Base Act?
Outer Continental Shelf Act?
Federal Employers Liability Act?
Jones Act?
Migration & Seasonal Workers Act?
Aviation Safety & Loss Control Program(s)
Do you have a written statement of safety policy?
*
Yes
No
Do you have a written safety program with responsibility assigned?
*
Yes
No
Do you have regular safety meetings with documentation?
*
Yes
No
Do you have a safety-based rewards program?
*
Yes
No
Have you been inspected by OSHA?
*
Yes
No
Is safety training included in new employee orientation?
*
Yes
No
Do you have a formalized training program?
*
Yes
No
Do you investigate all Workers' Compensation injuries?
*
Yes
No
Signature
Date
-
Month
-
Day
Year
Date
Submit
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