AIRCRAFT INSURANCE APPLICATION

(Check which is desired) A QUOTATION INSURANCE

Applicant

Address

City	State	Zip

Business of Applicant

Applicant is: Individual Corporation Partnership Other

Requested Coverage Period: / /20 to / /20

AIRCRAFT 1: Is aircraft operational and Airworthiness Certificate in full force and in effect? YES NO

If “NO” explain

Is the aircraft operated under a FAA Standard Airworthiness Certificate?	YES NO

If “NO” describe category

Has aircraft and /or engine(s) been modified?	YES NO

If “YES” explain

Is there any unrepaired damage to the aircraft (minor or major)?	YES NO

If “YES” explain

Make And Model

Year

FAA

Cert.

Num	Seating Capacity

Crew Pass

Land (L)

Sea (S)

Purchased Date

New/Used	Price Paid By Applicant	Present

Value

Engine Hrs.

New or

Major Overhaul

Engine

Make

And HP
1.
Note: Place additional aircraft on supplemental application.

LIABILITY COVERAGE

LIMITS OF LIABILITY

LIABILITY

PREMIUMS

EACH PERSON	EACH

OCCURRENCE
Single Limit Bodily Injury and Property Damage

including Passengers

Passenger Liability limited to:

XXXX	$	$
$

XXXXX	$
E. Medical Expenses	$	$	$
Other Liability	$	$	$

PHYSICAL DAMAGE COVERAGE – Aircraft 1

F. Open Peril Basis: GROUND AND FLIGHT

1. Agreed Value $

Deductibles $

$
G. Open Peril Basis: NOT IN MOTION

1. Agreed Value $

Deductible $

$

PURPOSE OF USE: (Check all applicable uses)

Pleasure or Business	Instruction and Rental

Corporate-Executive, flown by professional pilots employed for this purpose	Flying Club

Patrol Flights	Passenger Carrying- For Hire

Other Uses not indicated above (explain)	Aerial Photo / Survey

AIRCRAFT 1 - APPLICANT IS: Sole owner Owner subject to mortgage or conditional sales contract.

Other- explain:

If aircraft is mortgaged, please provide the following information:

Mortgage Name

Mortgage Address

City	State	Zip

Loan #

Amount of mortgage (excluding interest and finance charges)	$

Will Breach of Warranty Coverage be required for mortgage?	$

THE PILOT(S) FLYING AIRCRAFT 1: This information is required for each pilot who will operate aircraft 1 during the policy term

Pilot Certificate and Ratings LOGGED PILOT HOURS

Name

Date

Of

Birth

m/d/y	Stud	Pvt	Com’l	ATP	ASEL	AMEL	Instrument	Other

Total

A/C

Model

Insured	Multi

Engine	Ret

Gear	Sea Plane

Tailwheel

Equipped A/C

Last 12

1.
2.
3.
4.
Pilot No.	FAA Pilot Certificate No.	Date of Physical/Certificate
1.
2.
3.
4.

Name and address of pilots’ employer, if other than the applicant:

Employer Name

Employer Address

City	State	Zip

For Student pilots, include flight school and instructor name:

Flight School

Instructor Name

1.	Do any pilots named above have any physical impairments, waivers, limitations or conditions attached to their medical certificate?	YES NO

If YES, explain

2.	Has FAA or Military Pilot Certificate held by any pilot named above ever been suspended or revoked? YES NO

If YES, explain

3.	Has any pilot named above ever been cited for any violation of Federal Air Regulations or Administrative Action?

YES NO

If YES, explain

4.	Has any pilot named above ever been involved in any aircraft accident, aviation losses, claims or incidents?

YES NO

If YES, explain

5.	Has any pilot named above been convicted of or pleaded guilty to (a) charge of reckless driving or driving under the influence of alcohol or drugs? (b) Felony?	YES NO

If YES, explain & provide date

AIRCRAFT 1 - AIRCRAFT OPERATION

Number of hours aircraft was flown during the PAST 12 MONTHS

Estimated hours to fly NEXT 12 MONTHS

Aircraft based at and Hangared Tied-down at:

Airport

City	State

PUBLIC
AIRPORT

PRIVATE
AIRPORT	TOWER

RUNWAYS PAVED?

RUNWAYS LIGHTS?	Yes No

Yes No

Yes No
Airport Identifier	Length FT

Will aircraft be operated at other than paved public airports?	NO YES

Where? Purpose? Length?

Will aircraft be operated outside the 48 contiguous states of U.S.A.?	NO YES

Where? Purpose? Frequency?

How frequently does applicant use non-owned aircraft?

Will aircraft be used for student or pilot instruction?	NO YES

If “Yes” explain

Does applicant own other aircraft?	NO YES

If “Yes” list make(s) and model(s)

LOSS HISTORY AND PREVIOUS AVIATION INSURANCE PLEASE EXPLAIN EACH “YES” ANSWER BELOW:

1. Has applicant had any aircraft/aviation losses, claims or incidents during the last five years? NO YES

2. Has any insurer cancelled, declined, sent notice of cancellation, or refused to renew any aviation insurance?

NO YES (Not applicable in the following states: Missouri).

If “Yes” explain

3. Name of Last or Present Aircraft Insurance Company:

Expiration date:

All particulars herein are true and complete to the best of my 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 this Company to investigate all or any qualifications or statements contained herein.

FRAUD WARNING

(All States except: AR; CO; DC; FL; HI; KY; LA; ME; MD; NJ; NM; NY; OH; OK; OR; PA; TN; VA, VT; WA; WV)

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

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

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.

District of Columbia - It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida - 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 of the third degree.

Hawaii – For your protection, Hawaii Law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Kentucky – 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.

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

Maine – 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.

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

New Jersey – Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New Mexico – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

New York – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Ohio - any person, who, with intent to defraud or knowing that he/she is facilitating a fraud against any insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oregon – Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law.

Oklahoma – Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 such person to criminal and civil penalties.

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

Vermont - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties.

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

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 include imprisonment, fines and denial of insurance benefits.

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

Acceptance or Rejection of Terrorism Insurance Coverage

I hereby elect to purchase terrorism coverage for a prospective premium of $ .

I hereby decline to purchase terrorism coverage for certified acts of terrorism. I understand that I will have no coverage for losses resulting from certified acts of terrorism.

Date	Applicant’s Signature

Policy Number:

This application does not commit the Company to any liability nor make the Applicant liable for any premium unless the Company agrees to effect this insurance.

(This Applicant’s insurance agent may not sign this Application for the applicant.)

Producer:

Address:

City:

State:	Zip:	Phone No.:	Fax No.:

Includes copyrighted material of Insurance Services Office, Inc. with its permission.
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QBAV-3010 (05-11)
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QBAV-3010 (05-11)

QBAV-3010 (05-11)
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madkins

2013-03-21

dprk82

QBE the Americas