RENEWAL QUESTIONNAIRE

TURBINE AIRCRAFT

Check which is desired: Renewal Quotation Renewal Policy
NAME OF POLICYHOLDER/AIRCRAFT OWNER:
Policy Period effective from 12:01 A.M. to12:01 A.M. (local time at address of Policyholder)
Are any changes or alternate quotations requested for LIABILITY COVERAGES? Yes No If “Yes,” describe:

Physical Damage Coverage

Aircraft Year, Make and Model	Aircraft Registration	Aircraft Insured Value Requested	Aircraft Based at (Airport)	Hgrd.	Tied	Flight hours last 12 months	Estimated flight hours next 12 months
1.	$
2.	$
3.	$
4.	$
5.	$
Any changes in lien or lienholder? Yes No If “Yes”, describe:
Are engines, spare engines, or other aircraft equipment subject to separate lien or ownership? Yes No If “Yes”, describe:

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.
Have any of the aircraft been upgraded for TCAS, RVSM, or TAWS? If “Yes”, please provide details.
Are flights made to U.S. Military Installations? Yes No
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.

Premises

Locations of all premises used by the policyholder in connection with flight operations:

Pilots: Complete information below for all employed and contract pilots who will operate insured aircraft. Complete a PILOT QUESTIONNAIRE if it has not been previously submitted for any pilot.

Name of pilot Make & Models of Aircraft flown 1) 2)
Aircraft	Total Logged hours as PIC	Total ME	Total Turbine ME	Number of Logged Flying Hours in last 90 days	Number of Logged Flying hours in last 12 Months	Estimated number of flying hours in next 12 months
1
2

Training in Last 12 Months	Make & Model of Aircraft	Training program utilized	Frequency	Name of Training Facility
Simulator-based flight and ground school Contracted outside service In-house training using insured aircraft	Initial 6 Mo. 12 Mo. Recurrent In-house training using insured aircraft Other

Name of pilot Make & Models of Aircraft flown 1) 2)
Aircraft	Total Logged hours as PIC	Total ME	Total Turbine ME	Number of Logged Flying Hours in last 90 days	Number of Logged Flying hours in last 12 Months	Estimated number of flying hours in next 12 months
1
2

Training in Last 12 Months	Make & Model of Aircraft	Training program utilized	Frequency	Name of Training Facility
Simulator-based flight and ground school Contracted outside service In-house training using insured aircraft	Initial 6 Mo. 12 Mo. Recurrent In-house training using insured aircraft Other

Name of pilot Make & Models of Aircraft flown 1) 2)
Aircraft	Total Logged hours as PIC	Total ME	Total Turbine ME	Number of Logged Flying Hours in last 90 days	Number of Logged Flying hours in last 12 Months	Estimated number of flying hours in next 12 months
1
2

Training in Last 12 Months	Make & Model of Aircraft	Training program utilized	Frequency	Name of Training Facility
Simulator-based flight and ground school Contracted outside service In-house training using insured aircraft	Initial 6 Mo. 12 Mo. Recurrent In-house training using insured aircraft Other

Name of pilot Make & Models of Aircraft flown 1) 2)
Aircraft	Total Logged hours as PIC	Total ME	Total Turbine ME	Number of Logged Flying Hours in last 90 days	Number of Logged Flying hours in last 12 Months	Estimated number of flying hours in next 12 months
1
2

Training in Last 12 Months	Make & Model of Aircraft	Training program utilized	Frequency	Name of Training Facility
Simulator-based flight and ground school Contracted outside service In-house training using insured aircraft	Initial 6 Mo. 12 Mo. Recurrent In-house training using insured aircraft Other

Name of pilot Make & Models of Aircraft flown 1) 2)
Aircraft	Total Logged hours as PIC	Total ME	Total Turbine ME	Number of Logged Flying Hours in last 90 days	Number of Logged Flying hours in last 12 Months	Estimated number of flying hours in next 12 months
1
2

Training in Last 12 Months	Make & Model of Aircraft	Training program utilized	Frequency	Name of Training Facility
Simulator-based flight and ground school Contracted outside service In-house training using insured aircraft	Initial 6 Mo. 12 Mo. Recurrent In-house training using insured aircraft Other

Attach separate sheet for additional pilots if necessary.

Is there any other pertinent information or any other changes in exposure which materially affect this risk? Yes No If “Yes”, describe:

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?