Fixed Based Operations Insurance
General Information
Bref:
Applicants Name:
Please list any other names the business is or has been known by:
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Proposed Effective Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Applicant is
Individual
Corperation
Partnership
Joint Venture
Other
If OTHER please specify:
Date business began operations:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Person:
First Name
Last Name
Email:
example@example.com
Phone Number:
-
Area Code
Phone Number
Detailed description of business activities (specifically, and by location):
Physical Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Population within 50 miles:
Other Locations Used:
Names of business owner(s) names:
Date of Employment:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Experience in Aviation:
Please list the manager(s) of the proposed insured:
Annual Payroll:
Total Number of Employees:
Full Time Employees:
Part Time Employees:
GSE (Ground Support Equipment) to be insured:
Rows
Value
Diesel Tug
Electric Tug
Fuel Truck Jet-A
Fuel Truck Avgas
GPU
Other airside vehicles
Please describe the business’s drug policy, if any, and what the procedure is when an applicant or employee fails a drug test: (if none, state “None”)
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Insurance History
Who is your current insurance carrier (or your last if no current provider)?
Provide name(s) for all insurance companies that have provided insurance for the last three years:
Has the Applicant or any predecessor ever had a claim?
Yes
No
Completed Claims and Loss History (list details below)
Yes
No
Desired Insurance
Hangar Liability
Owned Aircraft
Hangar Keeper’s Legal Liability (HKLL)
Products and Completed Operations
Liability Insurance: Physical Damage to non-owned aircraftused for business only
Directors and Officers Liability
Professional Indemnity Liability
Limit of Liability
Business Activities
List all location(s) owned or from which you operate (useseparate sheet if necessary). Please list full address, city, countryand description of use. Show main location as number 1.
Rows
Locations
1
2
3
4
5
6
7
8
9
10
Description of use for each location listed:
Location 1:
Location 2:
Location 3:
Location 4:
Location 5:
Location 6:
Location 7:
Location 8:
Location 9:
Location 10:
Please specify your annual gross receipts for each of the followingcategories if applicable:
Rows
Actual Sales
12 month
Physical Repair (Aircraft Body) of Aircraft - Gross Income *
Sales of Aircraft Parts and Supplies - Gross Sales
Used Aircraft Sales - Gross Sales
New Aircraft Sales - Gross Sales
Leased Aircraft Sales - Gross Sales
Gasoline - Gallons Sold
Storage of Aircraft - Gross Income
Mechanical Repair and Service to aircraft -tune-up, air conditioning, lube and oil, brakes, engine rebuilding- Gross Income
Experimental or Homebuilt/Ultralight Aircraft Repair, - Gross Income
Rental of Aircraft - etc.-Gross Income
Tire Sales and Service-Gross Sales
Parking-Gross Sales
All Other Income-Explain
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Retail Sales
Is anyone other than employees allowed to work on aircraft onpremises?
Yes
No
If yes, please explain:
If Aircraft is outside, is apron completely enclosed by a chain linkfence or chain and posts not more than four feet apart?
Yes
No
Not more than 6ft apart
Is apron completely floodlighted?
Yes
No
Please explain
Is there police, security force or other protection?
Yes
No
Please explain
Do you pick up or deliver Aircraft?
Yes
No
Please explain
Do you repossess Aircraft?
Yes
No
If yes, please list number of repossessions annually:
If you are a wholesaler, do you maintain a separate storage facility?
Yes
No
If yes, please explain:
Do you consign Aircraft to sell?
Yes
No
If yes, how are they insured?
Average number of aircraft sold annually: (TOTAL)
Retail
Wholesale
Average number of aircraft for sale at one time:
Please complete a Schedule of Named Pilots, listing Pilots to be specifically insured (no coverage will be afforded unless all Pilots who are authorized to use an Aircraft are listed) Please include their age, licenses and experience in full
Please list all aircraft owned and licensed by you and used in your business including aircraft make/model,registration, configuration and agreed value for insurance.
Please list all aircraft to be managed by you and used in your business including the aircraft owners name, aircraft make/model, registration, configuration and agreed value for insurance.
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