Commercial Airport Liability Application
Applicant Name
*
Applicant is:
Government
Corporation
Partnership
Estate
LLC
Other
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
First Name
Last Name
Desired Effective Date
*
-
Month
-
Day
Year
Date
Does the Insured currently have an Aviation CGL policy with another carrier having more than 90 days left in the policy period?
*
Yes
No
Does airport board/authority/commission or transportation authority operate airport?
Yes
No
Does applicant submit airport insurance for public bid annually?
Yes
No
Does applicant maintain insurance for all other non-airport operations through commercial insurance carriers?
Yes
No
Premises/Location Information
Airport Identifier
*
Airport Name
*
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FAA Airport Classification
*
Airport altitude
*
Operating Days/Hours are:
*
Applicant interest in Airport is:
*
Owner
Lessor
Control Tower Operation:
*
FAA
No Control Tower
Other
Does Applicant Operate Unicom Service?
*
Yes
No
Does applicant have air shows, contests or exhibitions on premises.
*
Yes
No
Does applicant maintain/operate fuel storage facilities?
*
Yes
No
If "yes," tanks are
Above Ground
Below Ground
Frequency of Inspections (Fuel Storage)
Are any Navaids, Radars, Windshear detectors or aircraft communications owned, leased or mantained by applicant?
*
Yes
No
Does Applicant Base Fire Fighting vehicles on the Airport full time?
*
Yes
No
If no, how far away is nearest Fire Department:
Does Applicant Employ Medical Personnel?
*
Yes
No
If so, do they have their own insurance coverage?
Yes
No
Does Applicant:
Rows
Yes/No
Maintain Air Crash Emergency Plan?
Yes
No
Maintain Anti-Terrorist Plan?
Yes
No
Maintain Wildlife and Bird Strike prevention program?
Yes
No
Who is responsible for maintenance of these premises?
*
Any Non-Aviation Activities on Airport?
*
Yes
No
Non-Aviation Activities on Airport:
Lodging
Industrial Park
Storage
Farming
Other
Number of:
*
Rows
#
General aviation aircraft movements
Commuter airlines aircraft movements
Other airlines aircraft movements
Military aircraft movements
Elevators
Escalators
Moving Sidewalks
Automated Passenger Trains
Automatic Doors
Runways
*
Rows
Runway #
Length
1
2
3
4
List all Carriers Using the Airport:
*
Products and Completed Operations
Describe Insured Operations:
*
Gross Receipts by Operation
*
Rows
Does Applicant Engage in?
$ Prior 12 Months
$ Current 12 Months
$ Next 12 Months (estimated)
Fueling
Yes
No
Aircraft Maintenance/Repairs
Yes
No
Aircraft Parts/Accessories Sales
Yes
No
Cargo/Baggage Handling or Storage
Yes
No
Jetway or Planemate Operation
Yes
No
Passenger or Baggage Security Operations
Yes
No
Aircraft Towing
Yes
No
Aircraft De-icing
Yes
No
Restaurant/Vending Machine Operations
Yes
No
Airline ground support services
Yes
No
Control Tower
Yes
No
Hangar rental/lease
Yes
No
TIe-Down Rental/lease
Yes
No
Other
Yes
No
Hangarkeepers Liability
Number of Hangars:
*
Number of Tie-Down Spaces:
*
Describe Hangars (Show age, construction materials, size & if sprinklered)
*
Average value any one aircraft:
*
Maximum value any one aircraft:
*
Total value all aircraft:
*
Maximum value any one hangar:
*
Maximum value any one tie-down:
*
Desired Coverages
Desired Coverages
*
Rows
Desired
Per Occurrence
Aggregate
Premises Liability
Products/Completed Operations
On Premises Auto Liability
Personal Injury & Advertising Injury
Medical Expense (Per Person/Per Occurence)
Hangarkeeper's Liability (Per Aircraft/Per Loss)
Desired Limit for Fire Legal Liability (Damage to Premises Rented)
War & TRIA (Terrorism Coverage) desired?
*
Yes
No
Current Insurance (If Applicable)
Rows
Insurance Company
Premium
Expiration Date
Current Insurance
Construction, Demolition & Alterations
Contract costs this year for:
Rows
RUNWAYS
OTHER
Describe Work
By Applicant
By Independent Contractors
Is there an owners controlled insurance program?
*
Yes
No
Limit:
If No, minimum limit required of independent contractors:
Contractual Liability
CONTRACTS HELD WITH THE FOLLOWING OPERATIONS:
Rows
MINIMUM REQUIRED LIMITS
Is Applicant Held Harmless?
Is Applicant Additional Insured
Commuters & Airlines
Yes
No
Yes
No
Fixed Base Operators
Yes
No
Yes
No
Concessionaires
Yes
No
Yes
No
Contractors
Yes
No
Yes
No
Control Tower Operator
Yes
No
Yes
No
Janitors, escalator maintenance, security
Yes
No
Yes
No
Any contracts in which you assume the liability of others?
*
Yes
No
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Vehicles
Does applicant own, operate, or lease automobiles
*
Yes
No
Does applicant maintain automobile liability coverage
Yes
No
Liability Limit?
Number of vehicles owned by, operated by or leased to applicant.
Rows
#
Snow Removal equipment
Fuel trucks
Sweepers
Tugs
Crash-fire-rescue vehicles
Hydrant Carts
Passenger cars
Pickup Trucks
Passenger buses over 30 seats
Passenger buses under 30 seats
Non-owned Aircraft
Does airport use non-owned aircraft on airport business?
*
Yes
No
If yes, do employeespilot aircraft on airport business?
Yes
No
Describe Types of Aircraft Flown:
Number of Hours Flown
Rows
By Employees
By Others
In all non-owned aircraft on applicant's business
In chartered aircraft
In rented / leased aircraft
In borrowed aircraft
Past Claims
Has Insured been involved in an aviation incident or accident resulting in a loss or claim within the past 5 years?
*
Yes
No
If yes, describe:
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: