APPLICATION FOR AIRPORT LIABILITY INSURANCE

Name of Applicant:
Address:
Business of Applicant:
Form of Business: Public entity Individual Partnership Joint Venture Other (Describe)
Insurance is requested from 12:01 A.M. to 12:01 A.M. (local time at address of applicant)

Coverages requested	Limits of Insurance
Bodily injury and property damage liability:	$	Aggregate
Personal and advertising injury liability:	$	Aggregate
Medical payments:	$	Each person
Hangarkeeper’s liability:	$	Each loss
Deductibles requested:	$	Each occurrence:	$ Aggregate
Other requested coverages:
Additional insureds:

Name and Location of all Airport(s)	Interest in Premises	Occupancy	Certified FAA Part 139 Airport?	If not a Part 139 Airport, is the airport completely fenced?
Airport 1:	Owner Lessee Other (Describe)	Entire Part (Describe)	Yes No	Yes No
Airport 2:	Owner Lessee Other (Describe)	Entire Part (Describe)	Yes No	Yes No
Airport 3:	Owner Lessee Other (Describe)	Entire Part (Describe)	Yes No	Yes No

Manager of Airport Described Above	Manager’s Year of Experience in Airport Operations	Length of Employment with Applicant
Airport 1:
Airport 2:
Airport 3:

Description and location of other premises or facilities used permanently, occasionally or on a temporary basis in conjunction with airport or business described above:

Do airport premises contain:	Location	Quantity	Maintained by
Elevators?	No	Yes. Please describe:
Escalators?	No	Yes. Please describe:
Moving sidewalks?	No	Yes. Please describe:
Electric doors?	No	Yes. Please describe:
Passenger trams?	No	Yes. Please describe:

Who is responsible for inspection and maintenance of ramps, taxiways and runways?
Who is responsible for snow removal, if applicable?
Who provides janitorial service?
Who employs janitorial staff?
Who owns fuel tank farms?
Who is responsible for their operation and maintenance?
Tanks are located:	Above ground	Name of Underground Storage Tank (UST) insurance company:
Below ground	Name of Environmental Impairment Liability insurance company:
UST and pollution insurance coverages provided:
Are there any active, inactive or abandoned dumps, landfills, or aircraft salvage yards on, adjacent to, or near airport?	Yes	No
If “Yes”, describe:

Are there any:
Airshows, contests or exhibitions held at the airport?	Yes	No
If “Yes”, please describe:
Who provides airshow insurance?	Is Applicant an Insured under policy?	Yes	No
What coverages and limits are provided?
Uses of non-owned aircraft on airport business, either chartered or piloted by airport employees?	Yes	No
If “Yes”, please describe usage or attach non-owned aircraft application:

Mobile Equipment: Describe all vehicles and mobile equipment operated by applicant (that are not insured elsewhere): Attach a separate sheet if necessary.
Location	Type	Special Equipment	Quantity	Location	Type	Special Equipment	Quantity
Are any vehicles or mobile equipment licensed for use on or used on public roads? Yes No
If “Yes”, describe:

Airport Traffic	Last Year (Actual)	This Year (Actual/Estimated)	Next Year (Estimated)
Total annual number of airline passenger enplanements and deplanements:
Annual aircraft operations (Take-offs and Landings):
Airlines/Commuter:
General Aviation/Air Taxi:
Cargo:
Military:
Total:
Largest aircraft type regularly using the airport:
Who is the operator?

Does the applicant engage in:	If applicable, please provide annual sales receipts for:
Last Year (Actual)	This Year (Estimated/Actual)	Next Year (Estimated)
Fueling Operations?
Sale of Fuel:	Yes No	$	$	$
Sale of Oil:	Yes No	$	$	$
Oil Company Training: (If so, how often and where?)	Yes No
NATA Safety First Training:	Yes No	$	$	$
Airline (except Regional – Regional Gallons (if any) should be included above):	Yes No	$	$	$
Fuel storage, wholesaling or flowage arrangements:	Yes No	$	$	$
Operation or ownership of fuel trucks, tanks or fuel hydrant system:	Yes No	$	$	$
De-Icing?
Airline Equipment:	Yes No	$	$	$
Non - Airline Equipment:	Yes No	$	$	$
Airline Servicing?
Security & Screening:	Yes No	$	$	$
Caterers & Cleaning:	Yes No	$	$	$
Baggage Handling:	Yes No	$	$	$
Cargo:	Yes No	$	$	$
Aircraft Products/Completed Operations?
Sale of New Aircraft:	Yes No	$	$	$
Sale of Used Aircraft:	Yes No	$	$	$
Sale of Parts (not installed):	Yes No	$	$	$
If “Yes”, Manufacturer New Parts Only:	Yes No
If “Yes”, Yellow Tagged or After Market:	Yes No
Repair Service:	Yes No	$	$	$

Does the applicant engage in:	If applicable, please provide annual sales receipts for:
Last Year (Actual)	This Year (Estimated/Actual)	Next Year (Estimated)
Aircraft Products/Completed Operations? (continued)
Any Maintenance Performed on Piston-Engine Aircraft:	Yes No	$	$	$
Pre-Buy Inspections:	Yes No	$	$	$
Airline Equipment:	Yes No	$	$	$
Sale of Food & Beverage?	Yes No	$	$	$
Vending Machines Only:	Yes No	$	$	$
Manufacture of any Products?	Yes No	$	$	$
If “Yes”, provide details:
Hangaring of Aircraft?
Rental or Lease of Hangars or Tie Downs:	Yes No	$	$	$
NATA Safety First Training:	Yes No	$	$	$
Do you have Hangar Lease Agreement with your Tenants? If so, please provide a copy.	Yes No	$	$	$
Does it hold the applicant harmless for damages in excess of at least $100,000?	Yes No	$	$	$
Does it hold the applicant harmless for Diminution of Value and Loss of Use/ Loss of Profits?	Yes No	$	$	$
Wood Frame Hanger:	Yes No	$	$	$
Sloped Ramp Area:	Yes No	$	$	$
Lektro Tugs Only:	Yes No	$	$	$
Ramp Surveillance Video:	Yes No	$	$	$
Hangar Surveillance Video:	Yes No	$	$	$
Lineman Audio Headsets:	Yes No	$	$	$
Average length of employment for lineman:
SOP 3 Wing Walkers and Tug:	Yes No	$	$	$
Towing, Moving, or Parking of Aircraft:	Yes No	$	$	$
Maximum Value of Aircraft in applicant’s Care, Custody or Control at any one time.	$
Total Value of all Aircraft:	$
Premises Operations? - If “Yes”, describe.	Description:
Rental or Lease to Others of Land or Buildings:	Yes No
Rental of Premises to Others for Retail Stores or Services:	Yes No
Other Aviation Activities On or Off Airport Premises:	Yes No
Any Non-Aviation Activities On or Off Airport Premises:	Yes No
Operation of UNICOM:	Yes No
Operation of control tower:	Yes No
Ownership and/or maintenance of navaids, windshear detectors, or aviation communications equipment:	Yes No
Ownership or use of runway anti-skid or deicing equipment, or icing/runway temperature/chemical mix monitoring systems, or braking action measurement equipment:	Yes No

During the next 12 months will the applicant be involved in:	If applicable, estimated costs of work performed by:
Applicant	Contractor
New construction?	Yes	No	$	$
Structural alterations?	Yes	No	$	$

Does applicant:
Have in force a bird strike prevention plan?	Yes	No
Maintain an air crash emergency plan?	Yes	No
Maintain other emergency plan?	Yes	No
If “Yes”, describe:

Insurance requirements for tenants or other parties:
Minimum liability limits you require them to carry:	Are you an additional insured under their policy?	Are you “held harmless” In your contract with them?
Airlines:	$	Yes	No	Yes	No
Police, Fire, EMS:	$	Yes	No	Yes	No
Fixed based operators:	$	Yes	No	Yes	No
Contractors:	$	Yes	No	Yes	No
Food/Liquor services:	$	Yes	No	Yes	No
Other tenants:	$	Yes	No	Yes	No
Other vendors (including security, parking and janitorial services):	$	Yes	No	Yes	No
Does applicant require all tenants and vendors to show proof of insurance (as appropriate) holding applicant harmless?	Yes	No
Are certificates of insurance maintained on file by applicant?	Yes	No
Has applicant signed any agreements assuming liability of others?	Yes	No
If “Yes”, attach copes of agreements.

Airport liability insurance now in effect:
Carrier:	Expiration Date:
Coverages, limits and deductibles:

Workers Compensation insurance now in effect:
Carrier:	Expiration Date:
Limits:

Has any insurer cancelled or refused to renew the applicant’s insurance? NOT APPLICABLE IN MO	Yes	No
Is insurance being requested by public bid?	Yes	No	If “Yes”, attach complete bid specifications.

Loss experience: List all claims for the last five years. Attach separate sheet if necessary. Attach insurance company loss run, if available.
Losses
Date	Description	Paid	Reserved	Expenses	Total
$	$	$	$
$	$	$	$
$	$	$	$
$	$	$	$
$	$	$	$
$	$	$	$
$	$	$	$
$	$	$	$
$	$	$	$
$	$	$	$
TOTAL	$

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?