HELICOPTER HULL AND LIABILITY

INSURANCE APPLICATION

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

Address

Business or Occupation of Applicant

Applicant is: Individual Corporation Partnership LLC Other

Is this a Holding Corporation? NO YES If YES, explain

Insurance is requested from / / to / /	Present Insurance expires / /

Your business is

Liability Coverages	Limits of Liability Desired
Each Person	Each Occurrence
A.	Bodily Injury, Excluding Passengers	$	$
B.	Passenger Bodily Injury	$	$
C.	Property Damage	XXXXX	$
D.	Single Limit Bodily Injury, Including Excluding Passengers, and Property Damage	XXXXX	$
E.	Medical Payments, Including Excluding Crew	$	$
Physical Damage Coverage	Agreed Value	Deductible
F.	Rotors in Motion and Not in Motion	$	$	%
G.	Rotors Not in Motion Only	$	$	%
Other Coverages:

Additional Insured: (Please show names and addresses of any additional insured that you require and explain the reason why you wish to name these entities as additional insureds)

PRESENT CARRIER
Your present aircraft insurance company is

Policy Expires:
Has any insurer cancelled, declined or refused to write any aviation insurance for you or one of your pilots?
NO YES
If YES, explain:
OWNERSHIP OF AIRCRAFT
Does any person or organization (apart from Applicant shown above) have a financial interest in the insured aircraft?
NO YES
Explain:
Names and addresses of: Co-Owner(s) Mortgagee(s) Lessor(s)
Amount of any lien or loan, excluding interest and/or finance charges	$
Does your lienholder require Lienholder’s interest insurance (Breach of Warranty)?	NO YES

AIRCRAFT INFORMATION
Make & Model	Year	F.A.A. No.	Seats	Purchased	Price Paid by Applicant (incl. extras)	Engine Hours Since New or Since Last Major Overhaul	Number of Hours Flown in the Last 12 Months	Estimate Flight Hours Next 12 Months
Crew	Pass	New or Used	Date
1.	$
2.	$
3.	$

Is aircraft equipped with any modifications not provided by manufacturer?	NO YES

If YES, Explain:
Aircraft is a landplane?	NO YES (If YES, describe)

It is usually hangared?	NO YES

Aircraft is usually based at:

PURPOSE OF USE
Pleasure and Business	Charter / Air Taxi	Flying Club
Student or Pilot Instruction	Commercial	Rental
Special Uses – Defined as

Will any charge (other than operating expenses) be made for the use of the aircraft?	NO YES

Will the aircraft be used for anything other than transporting people?	NO YES

UTILIZATION
Use	Annual Hours	Use	Annual Hours
Industrial Aid / Pleasure & Business	Fire Fighting / Power line Stringing / Agricultural / Cattle Herding
Passenger Carrying For Hire	Occasional Slung Cargo
Slung Cargo / Banner Towing	Dual Instruction Only
Seismological Onshore	Instruction without Limited Rental
Offshore	Instruction including Limited Rental
Power line / Pipeline Patrol / Traffic Watch / Police	Cinematography
Fire Support	Air Ambulance
Erection / Construction	Prisoner Transportation
Other (Explain):

PILOT INFORMATION

Data required on all pilots who will operate the aircraft during the policy term. If more than one pilot, copy and attach separate sheet(s) unless a pilot history form is completed by each pilot

PILOT NO.

Name
Birthdate / /	Soc. Sec. No. - -
Occupation	Year learned to fly
Date of last BFR / /	Last Medical / /
FAA Pilot Certificates held Student Private Commercial ATP CFI
Certificate No. Issue Date / /
Ratings ASEL AMEL ASES Instrument Rotorcraft
Pilot-In-Command Hours
All Aircraft	This Make & Model	Piston Rotorcraft
Total	Last 12 Months	Last 90 Days	Total	Last 90 Days	Total	Last 90 Days
Turbine Rotorcraft	Fixed Wing S/E

Retract. Gear	Fixed Wing S/E

Fixed Gear	Fixed Wing Multi-Engine
Total	Last 90 Days	Total	Last 90 Days	Total	Last 90 Days	Total	Last 90 Days

Refresher/Transition Courses: Describe and give dates of last courses attended
Accidents or Violations: Describe and give dates
Pilot Signature:______________________________________________________________	Date:_____________

Do any pilots have any physical impairments, waivers, limitations or conditions attached to their medical certificate?

NO YES

Has a FAA or military pilot certificate held by any named pilot above ever been suspended or revoked?

NO YES

Has any named pilot ever been cited for any violation of a Federal Aviation Regulation?	NO YES

Has any named pilot ever been involved in any aircraft incident or accident?	NO YES

Has any named pilot ever been indicted, convicted or pleaded guilty to:

a.	The use of drugs or narcotics, or reckless, intoxicated or drunk driving?	NO YES

b.	A Felony?	NO YES

Is there any unrepaired damage to the insured aircraft?	NO YES

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

Will the insured aircraft be flown to Alaska or countries outside the United States of America, Canada or Mexico? NO YES

Has applicant had any aircraft / aviation losses, claims or incidents in the last five (5) years?	NO YES

Please answer the following:

a.	Who will perform your Helicopter Airframe maintenance?

b.	What insurance does the party in 10.a.(above) carry for:

Premises Liability	BI/PD	$ Each Occurrence

Hangarkeepers’ Liability	PD	$ Each Aircraft

$ Each Loss

Does the Hangarkeepers’ coverage include Rotors In Motion?	NO YES

If YES, is the Rotors in Motion coverage for all purposes or just for other than “Flight”?

All Only Other than Flight

Products-Completed Operations	BI/PD	$ Aggregate

Have you entered into any contractual agreement with the party identified in 10.a. (above) whereby you have agreed to waive your rights of subrogation, or hold harmless or indemnify the party?	NO YES

(If YES, attach a copy of the agreement)

Please answer the following:

a.	Who will perform your Engine maintenance?

b.	What insurance does the party in 11.a. .(above) carry for:

Premises Liability	BI/PD	$ Each Occurrence

Hangarkeepers’ Liability	PD	$ Each Aircraft

$ Each Loss

Does the Hangarkeepers’ coverage include Rotors In Motion?	NO YES

If YES, is the Rotors in Motion coverage for all purposes or just for other than “Flight”?

All Only Other than Flight

Products-Completed Operations	BI/PD	$ Aggregate

c.	Have you entered into any contractual agreement with the party identified in 11. a. whereby you have agreed to waive your rights of subrogation, or hold harmless or indemnify the party?	NO YES
(If YES, attach a copy of the agreement)

If YES to any of questions 1 – 9, please explain:

All particulars herein are warranted 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.

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, with intent to defraud or knowingly that his is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

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 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, which is a crime.

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 with intent to defraud or knowingly that his is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Pennsylvania – Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to 7 years and payment of a fine of up to $15,000.

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.

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.)

Date:________________

Producer 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:	YES NO

NAME OF APPLICANT
IMPORTANT: COMPLETE ALL ITEMS

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QBE the Americas

2013-04-04

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