TURBINE AIRCRAFT INSURANCE APPLICATION

(Check which is desired) A QUOTATION	INSURANCE POLICY	Renewal Policy
Name of Applicant (Including D/B/A’s and Holding Companies)
ADDRESS

BUSINESS OR OCCUPATION OF APPLICANT
Applicant is: Individual Corporation Partnership LLC Other
Insurance is requested from 12:01 AM / / to 12:01 AM / /	Present Insurance expires / /

LIABILITY COVERAGE	LIMITS OF LIABILITY
EACH PERSON	EACH OCCURRENCE
Bodily Injury – Excluding Passengers	$	$
Property Damage	XXXX
Passenger Liability	$	$
Single Limit Bodily Injury And Property Damage

Including Excluding Passengers;

All Bodily Injury Limited to:

Passenger Liability limited to:

XXXX	$
$

XXXXX
Medical Expenses Including Crew Excluding Crew	$	$
Other Liability	$	$
PHYSICAL DAMAGE COVERAGE
F. ALL RISKS GROUND AND FLIGHT	1. Agreed Value $	Deductible $	%
2. Agreed Value $	Deductible $	%
G. ALL RISKS: NOT IN MOTION	1. Agreed Value $	Deductible $	%
2. Agreed Value $	Deductible $	%

AIRCRAFT INFORMATION
Make And Model	Year	FAA Reg. Num	Seats	Land (L)

Sea (S)

Amp (A)	PURCHASED	Price Paid By Applicant (Incl. Extras)	Present Estimated Value (Incl. Extras)	Engine Hrs. New or Last Major Overhaul	Engine Make And HP
Crew	Pass.
New or Used	Date
1.
2.
3.

AIRCRAFT: 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

PURPOSE OF USE: (Check all applicable uses)
Pleasure	Business (not flown by professional pilots employed for this purpose)	Instruction and Rental
Flying Club	Corporate-Executive ( flown by professional pilots employed for this purpose)	Photography
Patrol Flights	Passenger Carrying- For Hire

Banner Towing
Other Uses not indicated above (explain)

OWNERSHIP OF AIRCRAFT
Does any person or organization (apart from Applicant shown above) have a financial interest in the insured aircraft?
YES NO
If 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)?	YES NO

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

Pilot Certificate and Ratings	LOGGED PILOT HOURS
Name	Date

Of

Birth

m/d/y	Pvt	Com’l	ATP	ASEL	SMEL	Instrumt	Helicopr	Total	Make and Model	Multi Engine	Retract Gear	Rotor Wing	Turbo Prop	Turbo Jet	Last 12

Month in M/M
to be Insured
1.
2.
3.
4.
Pilot Training History
Pilot No.	Aircraft Type/Make & Model	Last Initial or Recurrent School Attended	Date Attended
1.
2.
3.
4.

Name and address of pilot(s) – employer

If other than the applicant

For student pilots, name instructor and flight school giving flight instruction

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

If YES, explain

Has FAA or Military Pilot Certificate held by any pilot named above ever been suspended or revoked?

YES NO

If YES, explain

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

YES NO

If YES, explain

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

YES NO

If YES, explain

7.	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?	YES NO

(b) Felony?	YES NO

If YES, to either (a) or (b) above, explain & provide date

OPEN PILOT PROVISIONS REQUESTED

AIRCRAFT OPERATION
Number of hours aircraft was flown during the PAST 12 MONTHS
Estimated hours to fly in NEXT 12 MONTHS

Aircraft based and Hangared Tied-down at:
Airport

Airport Identifier

Length ft

City State	PUBLIC AIRPORT	PRIVATE AIRPORT	TOWER	YES NO
RUNWAYS PAVED	YES NO
RUNWAY LIGHTS	YES NO
Will aircraft be operated at other than paved public airports?	YES NO

Where? Purpose? Length

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

Where? Purpose? Frequency?

How frequently does applicant use non-owned aircraft?

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

If YES, explain

Are other aircraft owned by applicant?	YES NO

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? YES NO

If YES, explain

2.	Name of Last or Present Aircraft Insurance Company:

Expiration date:

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; ME; MD; NJ; NY; OH; OK; OR; PA; VT)

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.)

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:	YES NO

NAME OF APPLICANT	IMPORTANT: COMPLETE ALL ITEMS

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QBAV-3024 (07-11)

QBAV-3024 (07-11)
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