Insurance Application Form

Aviation Insurance Application
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
E-mail*
Website
Applicant Information
Applicant Name*

First NameLast Name
Applicant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Operations of Applicant
Identify all operations performed and their estimated gross receipts for next 12 months.
Fixed Wing Aircraft Services
Fuel & Lubricants
Engine Overhaul
Fixed Wing Aircraft
New Aircraft Sales
Used Aircraft Sales
Aircraft Parts (Not Installed)
Tie-downs & Hangaring
Propeller/Blade Repair
Aircraft Charter
Instruction & Rental
Rotorwing Repair & Services
Auto Parking
Aircraft Parking
Restaurant/Catering
Avionics Repair
Interior Repairs
Aircraft Detailing
Curbside Check-in/Skycap
Runway/Airport Repairs
Airport Cleaning
Passenger Assistance
Cargo Handling
Aircraft Push-back
Passenger Screening
Security Services
Ground Equipment Services
Airline Repair & Overhaul
Deicing
Part Distribution
Other
Please describe
Please describe the operation(s) you provided gross receipts for in "Other"
Total Estimated Receipts (All Locations)
Total is calculated based on the amounts you provided above.
Receipts from the above categories are for the following types of aircrafts:*

General AviationAirlinesMilitary
Premises
List all buildings, hangars, ramps and all other premises to be insured:*
Applicant Occupies:*

AllPart of Premises
Applicant Is:*

OwnerTenantGeneral Lessee of Premises
Who is responsible for maintenace of these premises?*
Does the Applicant have air shows, contests, or exhibitions on premises?*

Yes. The Applicant does have air shows, contests, or exhibitions on the premises.No. The Applicant does not have air shows, contests, or exhibitions on the premises.
List all autos and mobile equipment such as aircraft tugs or fuel trucks used solely on the airport premises*
Runways*

PavedUnpaved
Shortest runway is:*
Please enter the length of the runway in feet
Approach Obstructions?*

NoYes
Describe runway obstructions:
Products & Completed Operations

Products & Services
Total Gross Receipts (Last 12 Months)*
To adjust this figure, you must edit the amounts provided under the heading "Operations of Applicant."
Total Gross Receipts (Estimated Next 12 Months)*
Please provide an estimate of your total gross receipts for the upcoming year.
Describe products & services:*
Type of aircraft worked on:*
Applicant is a dealer or distributor for:*
Are you a member of the Professional Aviation Maintenance Association (PAMA) or SAE International?*

Professional Aviation Maintenance Association (PAMA)SAE InternationalPAMA & SAE InternationalNot a member
How many of your employees are PAMA or SAE certified?
Estimated Gross Receipts Next 12 Months for Repair of:
Airframe & Components*
Please provide an estimate of your total gross receipts for the upcoming year.
Fixed Wing (%)*
Rotorwing (%)*
Engine & Components*
Please provide an estimate of your total gross receipts for the upcoming year.
Fixed Wing (%)*
Rotorwing (%)*
Avionics*
Please provide an estimate of your total gross receipts for the upcoming year.
Propellers*
Please provide an estimate of your total gross receipts for the upcoming year.
Rotorsystems*
Please provide an estimate of your total gross receipts for the upcoming year.
Estimated Gross Receipts Next 12 Months for:
Airframe painting*
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of NEW parts, not installed:*
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of USED parts, not installed:*
Please provide an estimate of your total gross receipts for the upcoming year.
Does applicant fuel / defuel any aircraft?

YesNo
Type of aircraft:
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of fuel & oil*
Please provide an estimate of your total gross receipts for the upcoming year.
Gallons*
Please provide an estimate of your total gross receipts for the upcoming year.
Pumping Fees*
Please provide an estimate of your total gross receipts for the upcoming year.
Gallons*
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of NEW aircraft (Piston):*
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of USED aircraft (Piston):*
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of NEW aircraft (Turbine):*
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of USED aircraft (Turbine):*
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of food and beverages (including vending machines and catering):*
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of other items and services: *
Please describe
Please provide an estimate of your total gross receipts for the upcoming year.
Airline servicing (other than fuel)*
Please describe
Please provide an estimate of your total gross receipts for the upcoming year.
Sale of Avionics*
Please provide an estimate of your total gross receipts for the upcoming year.
De-icing Services
Please provide an estimate of your total gross receipts for the upcoming year.
Has applicant performed any engine or airframe modification work?

YesNo
Please describe
Has applicant ever sold, serviced or repaired “ultra-light” or “homebuilt” aircraft

YesNo
Please describe
Hangarkeeper's Liability

Aircraft in applicant's care, custody or control
Average value any one aircraft *
Please provide an estimate of your total gross receipts for the upcoming year.
Average Total all aircraft *
Please provide an estimate of your total gross receipts for the upcoming year.
Average number
Maximum value any one aircraft*
Please provide an estimate of your total gross receipts for the upcoming year.
Maximum total all aircraft*
Please provide an estimate of your total gross receipts for the upcoming year.
Average number
Maximum value any one hanger*
Please provide an estimate of your total gross receipts for the upcoming year.
Describe hanger
Tied down*
Please provide an estimate of your total gross receipts for the upcoming year.
Number of tie downs
Gross receipts for next 12 months hanger rental*
Please provide an estimate of your total gross receipts for the upcoming year.
Gross receipts for next 12 months tie downs*
Please provide an estimate of your total gross receipts for the upcoming year.
Gross receipts for next 12 months Towing*
Please provide an estimate of your total gross receipts for the upcoming year.
Does applicant fly customer’s aircraft? *

YesNo
List all purposes of use:
Coverages & Limits Requested

Please provide the commencement / termination dates for the policy period & the Limits of Insurance for each Coverage applicable.
From

MonthDayYear
Until

MonthDayYear
Commercial General Liability
General Aggregate Limit
(other than Products/Completed Operations)
Each Occurrence Limit
Products/Completed Operations Aggregate Limit
Personal and Advertising Injury Aggregate Limit
Fire Damage Limit
(any one fire)
Medical Expense Limit
(any one person)
Hangerkeeper's Liability Coverage
Each Loss Limit
Hangarkeeper’s Liability Coverage
Each Aircraft Limit
Hangarkeeper’s Liability Coverage
Deductible for each aircraft/each occurrence
Hangarkeeper’s Liability Coverage
Policy Deductible
Each Occurrence*
Annual Aggregate*
Other coverages, restrictions, endorsements:*
Current Insurance
Insurance Company*
Expiry Date*

MonthDayYear
Premium*
Deductible*
Limits*
Coverages*
Claims/Loss History & FAR Violations

List all claims and FAR Violations for past 10 years:
APPLICANT CERTIFICATION

The Applicant certifies that the statements in this Application are true and that no material information has been withheld or suppressed. The Applicant agrees that this Application and the terms and conditions of the policy in use by the insurer shall be the basis of any contract between the Applicant and the Insurer. The Applicant hereby authorizes this Company to investigate all or any qualifications or statements contained herein. The Applicant understands that this application does not commit the Company to any liability nor make the Applicant liable for any premium unless the Company agrees to bind this insurance.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Applicant's Name*

First NameLast Name
Applicant's Title*
Applicant's Signature
Should be Empty:

Aviation Insurance Application

Applicant Information

Operations of Applicant

Premises

Products & Completed Operations

Estimated Gross Receipts Next 12 Months for Repair of:

Estimated Gross Receipts Next 12 Months for:

Hangarkeeper's Liability

Coverages & Limits Requested

Policy Deductible

Current Insurance

Claims/Loss History & FAR Violations