AVIATION OPERATIONS LIABILITY

INSURANCE APPLICATION

EACH ITEM MUST BE ANSWERED ACCURATELY AND IN DETAIL

(Check which is desired) A QUOTATION	INSURANCE POLICY	Renewal Policy
Name of Applicant:

Address:
Applicant Is:	Individual	Partnership*	Corporation	Municipality	Estate

*If Corporation or Partnership, give the names of Officers or Partners, listed below:

Coverage to be effective from / / to / /	Present Insurance expires / /

Name and Location of Airport(s) at which you perform “Aviation Operations”:
Airport Identifier:	Please complete separate Application for each Airport location.
F.A.A. Airport Classification:

Interest of Applicant in Airport:	Tenant General Lessee Airport Owner

Is Airport Fenced?	YES NO

Is a Fire Station on premises?	YES NO

If NO, who responds and how far away?

Describe your “Aviation Operations:”
Please answer the following:

a.	How many years have you been in business under this name?

b.	If less than 10 years, describe your previous experience over the past 10 years.

Who are your prime customers?
Attach a copy of your contract with each of your customers.

Is Tie Down & Hangaring Provided By Applicant: NO YES If YES, complete the following:

a. Do you rent Hangars or Tie Downs directly to the Aircraft Owners?	NO YES

b. Or Fixed Base Operators, who in turn rent to Aircraft Owners?	NO YES

c. Are Aircraft of others taxied, towed or moved by Applicant?	NO YES

d. Who provides Tie Down ropes, chains, etc.?

e. Number of:

Number of Aircraft:
Tied Down	In T-Hangars	In Multiple Aircraft Hangars
Highest Value Aircraft:
Tied Down	In T-Hangars	In Multiple Aircraft Hangars
Total Value All Aircraft Combined:
Tied Down	In T-Hangars	In Multiple Aircraft Hangars
Number of:	Ultra-light Aircraft	Helicopters

Please answer the following:

a. Does Applicant charge for Automobile Parking?	NO YES

If YES, give area:

b. Is Automobile Parking let out to contract?	NO YES

Total Number of Parking Spaces operated by Insured operated by Contractor

Is there a charge for parking?	NO YES

Name of Parking Facility Contractor

Is there any Valet Parking at Airport?	NO YES

Provided by?

Does Insured engage directly in any of the following operations? (If YES, provide Annual Receipts)

Current Year
Next Year
Annual Receipts
Annual Receipts
a	Sale of Aircraft	NO	YES
$
$
b	Aircraft Repairs and Service	NO	YES
$
$
c	Aircraft Parts Sold but not serviced	NO	YES
$
$
d	Ground Handling	NO	YES
$
$
e	Cargo/Baggage Handling	NO	YES
$
$
f	Skycap	NO	YES
$
$
g	Planemate Operations	NO	YES
$
$
h	Security Screening	NO	YES
$
$
i	Restaurant Operations	NO	YES
$
$
j	Plane Shuttle bus/Van Operations	NO	YES
$
$
k	Other	NO	YES
$
$
l	Are you planning to change any of your historical operations?	NO	YES
Explain below:

FUELING:	On Premises?	NO YES

Done by Applicant?	NO YES

Fueling is by:	Truck	Hydrant	Gas Pump	Gas Pit	Other

Fuel Storage Facilities:	Underground gallons	Above Ground gallons

Type of Fuel

Type of Fuel Sold:	AVGAS	JET FUEL	AUTO FUEL

Annual Sales (gallons):	Airline gallons General Aviation gallons	Military gallons

Turbine Engine Fuel: gallons

Does Applicant refuel / defuel any Scheduled Airlines?	NO YES

If YES, describe type of aircraft and number fueled per day.
What are your Annual Gross Receipts for fueling?

Airline

General Aviation

Estimated Structural Alterations:	Runways/Taxiways	All Other

By Independent Contractors – cost next 12 months:	$	$

By Applicant – cost next 12 months:	$	$

Does applicant own, operate or maintain any navigational aids or unicom?	NO YES

If YES, describe
Does Applicant own, operate or maintain any of the following?

Number	Who Maintains?

Elevators
Escalators
Moving Sidewalks
Fuel Trucks
Mowers
Snow Removal
Pick-Up Trucks
Fire Engine
Passenger Cars
Tugs
Fixed wing Aircraft owned by Applicant
Helicopters owned by Applicant
Other

EXCESS AUTOMOBILE LIABILITY – OFF PREMISES

(Not available in MA.)

Do you want coverage for Off Premises Excess Automobile Liability?	NO YES

If YES, complete the following:

Of the vehicles listed in question 17, how many routinely go off the Airport premises?

Describe the vehicles that routinely go off Airport Premises

Who is your Primary Automobile Insurance Company and the Policy Number?

What limits of liability are provided?

Have you had any Automobile Liability claims in the last 6 years greater than $50,000?	NO YES

If YES, describe:
EXCESS EMPLOYERS LIABILITY COVERAGE – EXCLUDING DISEASE

Do you want this coverage?	NO YES

If YES, complete the following:

Who is your primary Employers Liability Insurance Company and Policy Number?

What limits of liability are provided?

Have you had any Employers Liability claims in the last 6 years greater than $50,000?	NO YES

If YES, describe:

How many employees do you have?

What are your annual payrolls by W.C.A. class code?

Code	Payroll

Code	Payroll

Code	Payroll

Code	Payroll

Have you had any aviation liability claims during the current policy period or during the prior 5 years thereto?

NO YES

If YES, please provide:
Date of Loss	Description	Amount Paid	Amount Outstanding
NOTE: Please provide Loss Run for each year, including amount, complete description of each loss by date, amount paid and/or reserved for the past 6 years.

COVERAGE TO BE QUOTED

Single Limit Bodily Injury, and Property Damage Liability Combined $ each occurrence and annual aggregate as respects Products-Completed Operations Liability. Personal / Advertising Injury and Malpractice are included separately for a sub-limit of not more than $25,000,000 any one offense / aggregate over the Primary and Excess Policies combined.

PRESENT COVERAGES	Aviation Operations Liability

Present Company

Limits of Liability

Deductible

Expiration Date

During the last year, has any insurer cancelled or refused to renew the Applicant’s Aviation Insurance?

YES NO If YES, name Insurer, date and reason below.

REMARKS

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 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.

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.

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

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.

Date_______________________________

Applicant’s Signature___________________________________________________________________

All Owners Must Sign

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’s Signature___________________________________________________________________

Producer:

Address:

City:

State:	Phone No.:	Fax No.:

Are you licensed in the state where the risk is located as:	Surplus Lines Broker	License No.:

Agent	License No.:

By the Company of Issue (Item No. 3):	YES NO

NAME OF APPLICANT

Includes copyrighted material of Insurance Services Office, Inc., with its permission.
QBCM-0207 (07-10)
Page 4 of 7

Includes copyrighted material of Insurance Services Office, Inc. with its permission.
QB (-)
Page 3 of 7

QBAV-3016 (07-11)

QBAV-3016 (07-11)
Page 1 of 7

POLICY NUMBER:

COMMERCIAL INLAND MARINE

QBCM-0184 (07-10)

Includes copyrighted material of Insurance Services Office, Inc. with its permission.

QBCM-0184 (07-10)
Page 3 of 7

NAME OF APPLICANT
IMPORTANT: COMPLETE ALL ITEMS

QBAV-3016 (07-11)
Page 2 of 7

QBAV-3016 (07-11)	Page 5 of 7

QBAV-XXXX (07-11)

QBE the Americas

2013-03-26

dprk82

corporate templates

Document Services

QBE