APPLICATION FOR

AIRCRAFT HULL & LIABILITY INSURANCE

NON-TURBINE AIRCRAFT

CHECK WHICH IS DESIRED: A QUOTATION NEW INSURANCE POLICY RENEWAL POLICY
NAME OF APPLICANT (Including DBAs and Holding Companies):
ADDRESS:
BUSINESS OR OCCUPATION OF APPLICANT:
APPLICANT IS: INDIVIDUAL(S) CORPORATION PARTNERSHIP LLC OTHER
INSURANCE IS REQUESTED FROM 12:01 A.M. to 12:01 A.M. (local time at address of applicant)

Liability Coverage	LIMITS OF LIABILITY DESIRED
Each Person	Each Occurrence
SINGLE LIMIT BODILY INJURY AND PROPERTY DAMAGE LIABILITY: Passengers: included excluded	$ Each Passenger	$
OTHER LIABILITY:	$	$

MEDICAL EXPENSE Crew: included excluded	$ Each Passenger

Aircraft: If Airworthiness Certificate is other than Standard, please explain If engine is being operated beyond TBO, please explain
Year, Make and Model	FAA Registration Number	Seating Capacity	Land (L) Sea (S) Amph (A)	PURCHASED	Current Market Value (Incl. Extras)	No. of Hours Aircraft Flown In Last 12 Months	Est. No. of Hours Next 12 Months
Crew	Other	New or Used	Date
1.	$
2.	$
3.	$
4.	$

Aircraft usually based at: (Name of Home Airport. If Private Airport, give detailed location) Hangared Tied Down

Aircraft Equipped with the following:	Aircraft 1 TCAS TAWS ADS-B	Aircraft 2 TCAS TAWS ADS-B	Aircraft 3 TCAS TAWS ADS-B	Aircraft 4 TCAS TAWS ADS-B

Physical Damage Coverage	AMOUNT OF INSURANCE DESIRED (attach explanation if other than current market value)	DEDUCTIBLES
IN MOTION	NOT IN MOTION
AIRCRAFT 1 ALL RISK BASIS ALL RISK BASIS NOT IN FLIGHT ALL RISK BASIS NOT IN MOTION	$	NIL OTHER Please indicate amount	NIL OTHER Please indicate amount

Physical Damage Coverage	AMOUNT OF INSURANCE DESIRED (attach explanation if other than current market value)	DEDUCTIBLES
IN MOTION	NOT IN MOTION
AIRCRAFT 2 ALL RISK BASIS ALL RISK BASIS NOT IN FLIGHT ALL RISK BASIS NOT IN MOTION	$	NIL OTHER Please indicate amount	NIL OTHER Please indicate amount
AIRCRAFT 3 ALL RISK BASIS ALL RISK BASIS NOT IN FLIGHT ALL RISK BASIS NOT IN MOTION	$	NIL OTHER Please indicate amount	NIL OTHER Please indicate amount
AIRCRAFT 4 ALL RISK BASIS ALL RISK BASIS NOT IN FLIGHT ALL RISK BASIS NOT IN MOTION	$	NIL OTHER Please indicate amount	NIL OTHER Please indicate amount

PURPOSE OF USE (Check all applicable uses)

Pleasure or Business (not flown by professional pilots employed for this purpose) Instruction of: (Name of Student) Corporate Executive (flown by professional pilots employed for this purpose) Flying Club Low Altitude Photography Patrol Flights Banner Towing Crop Dusting Air Ambulance Air Hearse Other Uses not indicated above (explain) Use for which a charge is made (explain below)

Aircraft Operations

Is the policyholder the only operator of insured aircraft? Yes No
Do aircraft carry passengers for hire or engage in other operations for which a charge is made? Yes No If “Yes,” describe usage below and estimate number of revenue flight hours in next 12 months:	Estimated Revenue Flight Hours
FAR PART 91.501
FAR PART 135 under policy holder’s certificate
FAR PART 135 under another’s certificate Name of certificate holder
Other (describe)
Are any aircraft operated with a single pilot crew? Yes No If “Yes,” please answer the following and explain where necessary
Part 135 (if applicable) Yes No
Mountainous terrain airports Yes No
High Density Traffic Areas Yes No
Night Yes No
International Yes No
What is your Maximum permissible crew duty day hours
Have weather minima for single pilot operations been established? Yes No If yes, please provide details
Are there procedures in place to use Second-In-Command Pilots? Yes No
Estimated number of hours for single pilot operations annually
Average number of passengers carried
Percentage breakdown of passengers employees guests

Areas of aircraft operation: U.S.A. Canada Mexico Other countries (list)
Are aircraft operated on non-paved runways? Yes No If yes, please provide details
Address of the Flight Department
Year Flight Department was established?
Is there a Flight Department Operations Manual? Yes No
Are flights made to U.S. Military Installations? Yes No
Is there a full time safety management program? Yes No
Is there a full time centralized dispatch? Yes No
Is aircraft operator a member of NBAA, CBAA, HAI?
Has the policyholder signed any agreements or contracts assuming liability of others with respect to aircraft operations? Yes No If “Yes,” attach copies.

Non-Owned Aircraft

Do any employees (including pilots employed by your flight department) pilot aircraft not owned by the policyholder on the policyholder’s business? Yes No If “Yes,” describe usage or attach Non-Owned Aircraft Application
Do you charter aircraft for company business? Yes No
If Yes:
What type of aircraft do you charter? Please list the names of the operators from whom you charter Who is responsible for approving charters (ie, Risk Management, Director of Flight Ops, etc.)?
What is the hourly utilization?
Do you request a certificate of insurance from the operator? Yes No
What is the minimum limit of liability you will accept from the operator?
Do you anticipate use of temporary substitute aircraft during servicing or maintenance of insured aircraft? Yes No If “Yes,” describe purpose, types of aircraft used, and anticipated annual utilization.

PILOTS: Complete This Section (Including Items 1-5 on page 4) For Every Pilot Who Will Operate An Aircraft During The Policy Term Unless A Pilot Questionnaire Is Completed By The Pilot.

NAME OF PILOT	Date of Birth	Pilot Certification and Ratings	Medical Certificate	Hours Logged as Pilot in Command
Stud.	Pvt.	Com’l.	ASEL	AMEL	Instrumt.	ATP	Other	Date of Last Physical	Class	All Aircraft	In Aircraft Model To Be Insured
Total	Last 90 Days	Last 12 Mos.	Retract Gear	Multi- Engine	Total	Last 90 Days	Last 12 Mos.
1.
2.
3.
4.

Pilot No. 1	Pilot No. 2	Pilot No. 3	Pilot No. 4
FAA Certificate No.
Date of Last Biennial Flight Review
Name and address of pilot’s employer if other than applicant:
Date of last Simulator Training or details of other proficiency training.

TRAINING

Type of Aircraft	Training Program Utilized:	Frequency & Date of Last	Name of Facility
Pilot No, 1	Simulator-based flight and ground school	Initial
Contracted outside service	6 Mo. 12 Mo. Recurrent
In-house ground and flight using fleet aircraft	Other
Pilot No, 2	Simulator-based flight and ground school	Initial
Contracted outside service	6 Mo. 12 Mo. Recurrent
In-house ground and flight using fleet aircraft	Other
Pilot No, 3	Simulator-based flight and ground school	Initial
Contracted outside service	6 Mo. 12 Mo. Recurrent
In-house ground and flight using fleet aircraft	Other
Pilot No, 4	Simulator-based flight and ground school	Initial
Contracted outside service	6 Mo. 12 Mo. Recurrent
In-house ground and flight using fleet aircraft	Other

EXPLAIN CIRCUMSTANCES IF:

1. Any pilots named above have any; (a) physical impairments, (b) waivers, limitations, conditions on their medical certificates or on their airman certificates 2. An FAA, Military, or other pilot certificate held by any pilot named above has ever been suspended or revoked 3. Any pilot above has ever been cited for violation of any aviation regulations in any country 4. Any pilot named above has ever been involved in any aircraft accident 5. Any pilot named above has ever been convicted of or plead guilty to a felony or driving while intoxicated

Applicant is: Sole owner Owner subject to mortgage or conditional sales contract. Lessee Other – explain
If aircraft is encumbered, name and address of lienholder or lessor
Amount of encumbrance (excluding interest and finance charges) $ Will Breach of Warranty coverage be required by lienholder? Yes No
Name of last aviation insurance carrier (if none so state)
To the Applicant’s knowledge has any damage been sustained to, or have any claims been made by others that have arisen out of the operation of, any aircraft owned by or in the custody of the Applicant? Yes No If yes, please provide details
Claims History
Date of Occurrence	Amount Paid	Description of Loss
$
$
If additional space is required, please attach a copy of the loss runs.

Has any insurance company or underwriter at any time declined an application submitted by or canceled or refused to renew a policy held by the applicant or any of the pilots named herein with regard to any type of insurance? NOT APPLICABLE IN MO Yes No If so, explain circumstances:

FRAUD STATEMENTS

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 that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI and WV

Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

APPLICABLE IN COLORADO

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

APPLICABLE IN FLORIDA and OKLAHOMA

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).

APPLICABLE IN KANSAS

Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA and WASHINGTON

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

APPLICABLE IN MINNESOTA

A person who files a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime.

APPLICABLE IN PUERTO RICO

Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five(5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

APPLICABLE IN VERMONT

Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law.

All particulars herein are declared to be true and complete to the best of my/our knowledge and no information has been withheld or suppressed and I/we agree that this application and the terms and conditions of the policy in use by the insurer shall be the basis of any contract between me/us and the insurer. I hereby authorize the insurer to investigate all or any qualifications or statements contained herein. Date ___________________________ Applicant’s Signature(s) ____________________________________________________________________
THIS APPLICATION DOES NOT COMMIT THE INSURER TO ANY LIABILITY NOR MAKE THE APPLICANT LIABLE FOR ANY PREMIUM UNLESS AND UNTIL THE INSURER AGREES TO EFFECT THIS INSURANCE.

THE INSURANCE PRODUCER COMPLETES THE BELOW SECTION.

Name of Insurance Producer:
License State:	State License Number:
Address:
For how long have you been designated this applicant’s Broker of Record?