RENEWAL QUESTIONNAIRE/HELICOPTERS

NAME OF POLICYHOLDER/AIRCRAFT OWNER:
Policy Period effective from 12:01 A.M. to12:01 A.M. (local time at address of Policyholder)
Aircraft usually based at Hangared Tied-down
Make & Model helicopter insured:
Registration:	N	N	N	N
Insured Value of aircraft requested at renewal	$	$	$	$
Amount of encumbrance excluding interest and finance charges (if applicable)	$	$	$	$
Name and address of lienholder(s) (Specify by registration numbers): 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) Instructions-Pilot Upgrade Search and Rescue Heliskiing Business (Non-Professional Pilots) Charter Passenger Cargo Airline Patrol Flights (describe below) Crop Dusting Spraying Seeding Corporate-Executive (Flown by Air Ambulance Medivac External Load-Slung Cargo Professional Pilots Hired for this purpose) Police Operations Water-Bucket, Fire Control, Fire Support Pole/Inflight Pick Up and Delivery Instruction-Check Out Traffic Control Slash Burning Logging Other Uses Not Listed Areas of Operation
Are non-FAA approved landing sites used? Yes No If yes, how often? Describe Sites
Are building top landing pads used? Yes No If yes, how often? Give location and description
Are overwater flights contemplated? Yes No If yes, where, and how often?
Are floats installed? Yes No Percentage of Time? % Value? $
Are flights at night contemplated? Yes No How frequently? Are landing sites lighted?
Who performs maintenance?

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
Pvt.	Com’l.	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
1. Has the pilot successfully completed the manufacturer’s approved pilots’ ground and flight training school for this make and model helicopter? Specify make and model, location and date of training:	Yes No	Yes No	Yes No	Yes No
2. Does the pilot participate in a formal recurrent training program? (If Yes, attach brief summary)	Yes No	Yes No	Yes No	Yes No
3. Was the pilot’s original rotorcraft rating obtained through the military?	Yes No	Yes No	Yes No	Yes No
4. Does the pilot have any physical impairments? If Yes, Explain	Yes No	Yes No	Yes No	Yes No
5. Does the pilot have any waivers, restrictions, limitations or conditions attached to their medical certificate? If Yes, Explain	Yes No	Yes No	Yes No	Yes No
6. Has any pilot’s FAA, military or other pilot certificate ever been suspended or revoked? If Yes, Explain	Yes No	Yes No	Yes No	Yes No
7. Has any pilot ever been cited for any violation of any aviation regulation in any country? If Yes, Explain	Yes No	Yes No	Yes No	Yes No
8. Has any pilot ever been involved in an aircraft accident? If Yes, Explain	Yes No	Yes No	Yes No	Yes No
9. Has any pilot ever been convicted or pleaded guilty to a felony or driving while intoxicated? If Yes, Explain	Yes No	Yes No	Yes No	Yes No

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?