HELIPORT OPERATORS LIABILITY

INSURANCE APPLICATION

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

Address

Applicant Is:	Corporation*	Partnership*

Individual	Municipality

Estate

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

Insurance is requested for the period / / to / /

Name of Heliport:

Identifier:	located miles of

Heliport Manager:	Phone Number

APPLICANT IS: Tenant General Lessee Heliport Owner Present Insurance expires / /

OPERATIONS OF APPLICANT – indicate all operations and estimated annual gross receipts.
List all other sources and receipts below
Fuel & Lubricants	$	Helicopter Maintenance	$	Other:
Tie Down & Hangaring	$	Helicopter Charter	$	$
Landing Fees	$	Rental & Instruction	$	$
New Helicopters	$	Food & Beverages	$	$
Used Helicopters	$	Auto Parking	$	$
Helicopter Parts	$
Total	$
(Use separate sheet if necessary)

FUELING – On premises YES NO Done by applicant YES NO
IF FUELING IS DONE ON PREMISES AND/OR BY APPLICANT PLEASE ANSWER THE FOLLOWING:

Fueling is by: Truck Hydrant Gas pump Gas pit Other

Annual Gallonage: Airline gallons General Aviation gallons

Military gallons
Type of fuel sold: AVGAS JET FUEL AUTO FUEL
Fuel Storage Facilities: Underground gallons Above ground gallons

TIE DOWN & HANGARING by APPLICANT –

Are helicopters of others taxied, towed or moved by applicant? YES NO
Who provides tie down ropes/chains, etc.?
Number of:	Tie down spaces	T-hangars	Multiple-aircraft hangars
Number of aircraft:	Tied down	In T-hangars	In multiple-aircraft hangars
Highest value a/c:	Tied down	$	In T-hangars	$	In multiple-aircraft hangars	$
Total value all a/c:	Tied down	$	In T-hangars	$	In multiple-aircraft hangars	$

APPLICANT’S VEHICLES, ELEVATORS and AIRCRAFT
Indicate the number and type of vehicles maintained for use exclusively on the airport premises:
Fuel Trucks	Sweepers	Snow Removal	Fire Engines	Tugs
Hydrant Cars	Pickup Trucks	Passenger Cars	Other
State number of: Elevators Escalators Moving Sidewalks
State number of Aircraft owned or operated by applicant number of Helicopters

CONTRACTS
Has applicant entered into any written agreements assuming the liability of others, such as

Lease of premises, fuel supplier, equipment lease, etc.?	NO YES (attach copies)

Does applicant use uniform customer contracts for hangaring, service, etc.?	NO YES (attach copies)

Does applicant require “hold harmless” coverage?	NO YES

Give details of minimum limits required from: Airlines $ FBO’s $ Concessionaires $

Is applicant named as Additional Insured?	NO YES
CONSTRUCTION by INDEPENDENT CONTRACTORS – Show estimated cost by type of construction
Helipad & Taxiways	$ current year	$ next year	$ next three years
All others (describe)	$ current year	$ next year	$ next three years

NON-OWNED AIRCRAFT LIABILITY COVERAGE
Piloted by applicants employees:	Hours per year	Helicopter type	Maximum Seating
Piloted by others:	Hours per year	Helicopter type	Maximum Seating
Applicant's employee pilots must attach a pilot history form.

HELIPORT DESCRIPTION
Elevation is ft.	Pad Dimension:	(1) ft. x ft.	(2) ft. x ft.
Number of helicopters based at heliport:	Airline	General Aviation	Military
Helipad Construction: Concrete Turf Blacktop Other Is helipad lighted? NO YES
Is heliport on: Ground Rooftop – height above ground:
Obstructions:	(1) Type	Distance	Height
(2) Type	Distance	Height
Is helipad available for public use? NO YES
Is rotorcraft traffic controlled?	NO YES	By: FAA Non-Federal	Unicom Operated by:
Is there a heliport manager?	NO YES
Employed by: Applicant Independent Contractor (furnish copies of contract)
Is manager on premises during hours of operation?	NO YES	Hours of operation to
Fire protection located at helipad?	NO It is miles from the helipad YES
Is helipad area fenced?	NO YES	Who maintains the helipad?
Does the applicant own, operate or maintain any navigational aids?	NO YES (describe)
If applicant is Owner or General Lessee, enclose a diagram of premise or FAA Form 5010-1
Are airport premises used for any recreational or other non-aviation activities? NO YES (If YES, describe)
List Commercial Helicopter Service or Scheduled Air Taxi that serve heliport currently and during the next three years:
TRAINING: Describe training of ground personnel:
Largest value helicopter using heliport: Helicopter	Value $

Total Estimated Arrivals & Departures:	PRESENT YEAR	NEXT YEAR (EST)	FOLLOWING YEAR (EST)
Revenue Passengers (enplaned)
Airline Helicopter (landings)
General Aviation Helicopter (landings)
Military Helicopter (landings)

LIABILITY COVERAGE	EACH PERSON	EACH OCCURRENCE
State Limits of Liability Desired
Bodily Injury Liability	XXXX
Property Damage Liability	XXXX
Single Limit Bodily Injury and Property Damage	XXXX
EACH AIRCRAFT	EACH LOSS
Ground Hangarkeepers’ Liability

LOSS HISTORY and PREVIOUS AVIATION INSURANCE – Explain each “YES” Answer
Has applicant had any airport / aviation losses/claims during the last five years? YES NO
(Explanation should include description of Loss, Loss & Expense Reserves, Loss Payments and Total Incurred)
Explain:

Has any insurer cancelled, declined or refused to renew any airport / aviation insurance? YES NO
(Not applicable in the following states: Missouri
Explain:

Name of Last or Present Aircraft Insurance Company:

Present Limit of Liability: Present Deductible:
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.

(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
IMPORTANT: COMPLETE ALL ITEMS

QBAV-3023 (07-11)
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QBAV-3023 (07-11)

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QBE the Americas

2013-04-10

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