GENERAL AVIATION AIRPORT LIABILITY

INSURANCE APPLICATION

(Not for use if Airline or Commuter Operations involved)

EACH ITEM MUST BE ANSWERED ACCURATELY AND IN DETAIL

(Check which is desired) A QUOTATION	INSURANCE POLICY	Renewal Policy
Is this a Public Bid?	NO YES (If YES, the complete bid specifications must be attached)

Name of Applicant:

Address:
Applicant Is:	Corporation*	Partnership*

Individual	Estate

Municipality

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

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

Name and Location of Airport:
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

Runways:

HEADING	LENGTH	WIDTH	SURFACE
(a)
(b)
(c)
(d)

8.	Is Airport Fenced 100%?	NO YES	Is Airport Fenced Partially?	NO YES

9.	Is a Fire Station on premises?	NO YES

If NO, who responds and how far away?

10.	Please answer the following:

Is a Manager on premises 24 hours a day?	NO YES

If NO, when?

Is Airport Manager an employee of the Named Insured?	NO YES

If NO, of whom and supply a copy of the contract.

Does the Airport Manager carry out business at the Airport, aside from his/her duties as the Airport Manager?

NO YES

If YES, describe:

How much Insurance do they carry?

When does their coverage expire?

Do they hold you harmless?	NO YES

Does their Insurance Policy include you as an Additional Insured?	NO YES

Does the contract between you and the Airport Manager specifically outline:

His/her duties as Manager and	NO YES

Insurance requirements?	NO YES

11.	Are there any Non-Aviation activities at the Airport?	NO YES

If YES, describe:

12.	Total Aircraft Operations (Take-Offs and Landings):	This Fiscal Year	Next Fiscal Year

a.	General Aviation / Air Taxi

b.	Military

c.	Other

d.	Total Operations

13.	Please answer the following:

a.	Largest Aircraft Type commonly using the Airport:

b.	Who operates the Aircraft in (a)?

14.	Does Insured / Applicant engage directly in any of the following operations?

If YES, list Annual Receipts
a.	Aircraft Sold – New	NO	YES	$
Fixed Wing	NO	YES	$
Helicopter	NO	YES	$
b.	Aircraft Sold – Used	NO	YES	$
Fixed Wing	NO	YES	$
Helicopter	NO	YES	$
c.	Aircraft Repairs & Service (including parts installed)	NO	YES	$
Fixed Wing	NO	YES	$
Helicopter	NO	YES	$
d.	Aircraft Parts Sold – Not Installed	NO	YES	$
Fixed Wing	NO	YES	$
Helicopter	NO	YES	$
e.	Aircraft Fuel & Oil	NO	YES	$
f.	Airlines	NO	YES	$
g.	General Aviation (including Helicopters)	NO	YES	$
h.	Cargo Handling	NO	YES	$
i.	Cargo Storage	NO	YES	$
j.	Security Screening	NO	YES	$
j.	Rental & Instruction	NO	YES	$
k.	Restaurant Operations	NO	YES	$
l.	Automobile / Shuttle Bus	NO	YES	$
m..	Agricultural Operations	NO	YES	$
n.	Airmeets, Contests, Exhibitions	NO	YES	$
o.	Other Operations (describe below)	NO	YES	$

15.	FUELING:	On Premises? NO YES	Done by Applicant? NO YES

If Fueling is done on Premises and/or by Applicant please answer the following:

Fueling is by: Truck Hydrant Gas Pump Gas Pit Other

Fuel Storage Facilities: Underground gallons Above Ground gallons

Type of Fuel

Annual Gallonage:	Airline gallons General Aviation gallons Military gallons

Type of Fuel Sold:	AVGAS JET FUEL AUTO FUEL

Annual Gallonage of Turbine Engine Fuel: gallons

Does Applicant refuel / defuel any Scheduled Airlines?	NO YES

If YES, describe type of aircraft and number fueled per day.
Self-Serve Fuel: Does applicant provide Self-Serve Fuel on premises?	NO YES

If YES, who is responsible for Fuel and Equipment maintenance of tanks?

Who receives the profit from the sale of fuel?

16.	If you answered YES to Aircraft or Helicopter Repairs & Service, describe the type of Aircraft and Helicopters serviced and the scope of your work:

17.	AIR MEETS, CONTESTS, EXHIBITIONS – Our policy excludes Air Meets, Contests and Exhibitions without prior agreement, but does not exclude “Static Displays”. If you plan to have an Air Meet, Contest or Exhibition, different conditions will apply.

Contact your Insurance Agent for details.

18.	Is your Control Tower operated by the FAA?	NO YES

If NO:

a.	Who operates it?

b.	How much Insurance do they carry?

c.	When does their Insurance expire?

d.	Do they hold you harmless?

e.	Does their Insurance Policy include you as an Additional Insured?

19.	TIE DOWN & HANGARING BY APPLICANT:

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

If NO, who provides these services on premises?

If YES, provide information regarding training of employees for the performance of these duties:
Who provides Tie Down ropes, chains, etc.?

Number of:

Tied Down Spaces	T-Hangars	Multiple Aircraft Hangars
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

20.	PARKING:

Does Applicant charge for Automobile Parking?	NO YES

If YES, give area:

Total Number of Parking Spaces operated by Insured operated by Contractor

21.	Estimated Structural Alterations:	Runways/Taxiways	All Other

a.	By Independent Contractors – cost next 12 months:	$	$

b.	By Applicant – cost next 12 months:	$	$

22.	As respects Incidental Malpractice, do you employ any full-time Nurses, Doctors or EMT’s, and if so, please give full details including:

Number of each and the maximum number on duty at any one time:

23.	Does Applicant own, operate or maintain any of the following? Number	Who Maintains?

Elevators
b.	Escalators
c.	Moving Sidewalks
d.	Revolving Doors
e.	Fuel Trucks
f.	Mowers
g.	Snow Removal
h.	Pick-Up Trucks
Fire Engine / Fire Rescue
Are all vehicles restricted to on airport premises?	NO YES
If NO, provide details of off airport activities:
Passenger Cars
Tugs
Fixed wing Aircraft owned by Applicant
Helicopters owned by Applicant
Other

24.	AIRPORT SECURITY:

Airport Security is provided by:

If Applicant, provide number on duty at any one time: Policy / Security Fireman / Rescue

Other (please describe):

25.	Minimum Limits that you are requiring

Minimum Limits Required by You Should Not Be Less Than	Are You Named as an Additional Insured?	Are You Indemnified and Held Harmless?
a.	Fixed Base Operators	$2,000,000	NO YES	NO YES
b.	Concessionaires	$1,000,000	NO YES	NO YES
c.	Contractors	$5,000,000	NO YES	NO YES
d.	Others (describe below)
e.	Attach samples of your Standard Agreements. Are they all similar? If not, advise details on a separate sheet and/or provide copies of contracts.

VERY IMPORTANT

If the minimum limits required by you are not as high as those shown above, you must complete Page 9 of the Application. By leaving Page 9 blank you are representing that the Insured requires the minimum limits of liability as stated above.

26.	NON-OWNED AIRCRAFT LIABILITY ARISING OUT OF AIRPORT OPERATIONS:

a.	Number of hours per year when you use a Non-Owned Aircraft piloted by people other than employees of the Applicant and type of Aircraft and maximum seating:

b.	Number of hours per year when employees of Applicant use Non-Owned Aircraft on Applicant’s business and type of Aircraft and maximum seating:

c.	As respects (b) above, each employee pilot must complete Pilot History Form which may be obtained from your Agent.

d.	Have you had any Airport Liability or Non-Owned Aircraft Liability claims during the current policy period or during the prior 6 years thereto?	NO YES

If YES, please provide:
Date of Loss	Description	Amount Paid	Amount Outstanding
NOTE: If claim incurred is over $5,000., give breakdown of each claim by date, description and amount paid and/or reserved.

27.	COVERAGE & LIMITS REQUESTED

Limits: $ Each Occurrence – Combined Single Limit, Bodily Injury and Property Damage

(An annual aggregate applies to products/completed operations and personal injury/advertising liabilities)

Coverages:

Products & Completed Operations

Incidental Medical Malpractice Liability

Medical Payments: $ each person

Personal Injury Including Advertising Injury

Hangarkeepers Liability:	$ Each Aircraft

Deductible:	$ Each Occurrence

$	$ Each Loss

Fire Legal Liability:	$ Any One Fire

Other (Specify)

28.	PRESENT COVERAGES	Airport Liability

a.	Present Company:

b.	Limits of Liability:

c.	Deductible:

d.	Expiration Date:

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

(Insurer, date and reason)

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 an 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.

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

Producer:	Producer Signature:

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

If the Limit Required are Less Than the Minimum Limits shown under Item 25 of the Application Please Contact the Lessee / Permittee and Ascertain what Actual Limits are Carried

Fill It In Below
What Cancellation or Review Provisions are Contained in the Contract as Respects Insurance Requirements
What is the Renewal Date of Contract
Permittee / Lessee Include Airport as an Additional Insured
Does Contract with Permittee / Lessee Hold Harmless & Indemnify Airport
Limits of Liability Contract Requires Permittee / Lessee to Carry
Business of Permittee / Lessee
Permittee/ Lessee

NAME OF APPLICANT
IMPORTANT: COMPLETE ALL ITEMS

QBAV-3021 (07-11)
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Includes copyrighted material of Insurance Services Office, Inc. with its permission.
QB (-)
Page 3 of 9

QBAV-3021 (07-11)

QBAV-3021 (07-11)
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POLICY NUMBER:

COMMERCIAL INLAND MARINE

QBCM-0184 (07-10)

QBAV-3021 (07-11)
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QBE the Americas

2013-03-29

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