APPLICATION FOR
HELICOPTER HULL AND LIABILITY INSURANCE

Check which is desired:	A QUOTATION	INSURANCE POLICY	RENEWAL POLICY

Name of Applicant (Include DBAs and Holding Companies):
Address:
Business or occupation of applicant:
Applicant is: Corporation Individual(s) Partnership Other (Describe)
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	Physical Damage Coverage
Each Person	Each Occurrence
Single Limit Bodily Injury and Property Damage Liability: Passengers: included, excluded	$ Each Passenger	$	Amount of Hull Insurance
Aircraft 1: $
Aircraft 2: $
Other Liability	$	$	Deductibles $ %
Medical Expenses Crew - included, excluded	$ Each Person	Rotors not in motion:
Rotors in motion:

Aircraft	FAA Reg. No.	Seating Capacity	Purchased	Price Paid by Applicant (incl.extras)	Present Estimated Value (incl.extras)	Engine Hours Since New, or Since Last Major Overhaul	Number of Hours Flown in the Last 12 Months	Estimate Flight Hours Next 12 Months
Year, Make and Model	Crew	Pass	New or Used	Date
1.	$	$
2.	$	$
Description of special or extra equipment installed on aircraft and spares inventory
Aircraft 1.	Value: $
Aircraft 2.	Value: $
Spare Parts Inventory:	Value: $

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

Aircraft Use: check use(s) to which policy is to apply
Pleasure (non-professional pilots)	Instruction – Pilot upgrade	Search and Rescue	External Load – Slung Cargo
Business (non-professional pilots)	Charter: Pass Cargo	Patrol Flights (describe below)	Pole/Inflight Pick Up & Delivery
Corporate – Executive (flown by professional pilots hired for this purpose)	Air Ambulance, Medevac	Slash Burning	Logging
Instruction - Initial	Police Operations	Fire Control, Water Bucket, Fire Support	Heliskiing
Instruction – Check-out	Traffic Watch or News	Crop Dusting, Spraying, Seeding
Other uses not listed:

If used under FAR 135, who owns the FAR 135 operating certificate under which you operate?
Who maintains operational control of the aircraft being operated under FAR 135?
Is Airworthiness Certificate other than standard? Yes No If yes, explain
Is engine being operated beyond TBO? Yes No If yes, explain
Aircraft usually based at:	Hangared? Yes No
If private heliport, describe facilities and security:
Are landing sites not approved by FAA used? Yes No If yes, how often? Identify sites:
Are building top landing pads used? Yes No If yes, how often? Identify sites:
Areas of Operation:	FAR licenses held:
Are floats installed? Yes No If yes, percentage of time: % Value: $
Are flights at night contemplated? Yes No If yes, how frequently? Are landing sites lighted? Yes No
Who performs maintenance?

Pilots: COMPLETE THIS SECTION (INDLUDING ITEMS 1.-9. BELOW) 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	Helicopter Certificate and Ratings	Medical Certificate	Pilot in Command Hours - Logged	Estimated helicopter flight hours next 12 months
Helicopter
Private	Commercial	IFR	ATP	Type Ratings (List)	Date of Last Physical	Class	Total All Aircraft	Total Recip.	Total Turbine	In Model to be Insured	Total Last 12 Months
1.
2.
3.
4.

PILOT	1	2	3	4
Yes	No	Yes	No	Yes	No	Yes	No
1. Has the pilot successfully completed the manufacturer’s approved pilot ground and flight training school for any helicopter?
(Yes or No) Specify make and model: Date:
2. Does the pilot participate in a formal recurrent training program?
3. Was pilot’s original rotorcraft rating obtained through the military?
4. Does the pilot have any physical impairments?
5. Does the pilot have any waivers, restrictions, limitations or conditions attached to their medical certificate?
6. Has any pilot’s FAA, Transport Canada, military or other pilot certificate ever been suspended or revoked?
7. Has any pilot ever been cited for any violation of any aviation regulation in any country?
8. Has any pilot ever been involved in any aircraft accident?
9. Has any pilot ever been convicted or pleaded guilty to a felony or driving while intoxicated?
Explain all “yes” answers to these questions:

Member of NBAA? Yes No	Membership Type: Corporate Business Associate
Member of HAI? Yes No	Membership Type: Corporate Business Associate

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

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

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?