General Information

Premises - Operations :

Hangarkeepers Liability (Aircraft in your custody for storage/safekeeping/repair/servicing)

Claims, List all claims for past 5 years.
Include Date, Cause, Settled, Including all costs, Open Including Reserves for Defense and Settlement

Claim 1:

Claim 2:

Claim 3:

Claim 4:

Claim 5:

Name of Insurance Company: Expiration Date:

Coverages:

Limits: Deductibles: $ Premium: $

Coverage:			Limits of Insurance:
Commercial General Liability Coverage
	General Aggregate Limit (Other than Products/Completed Operations)		$
	Products/Completed Operations Aggregate Limit		$
	Personal and Advertising Injury Aggregate Limit		$
	Each Occurrence LImit		$
	Fire Damage Limit (any one fire)		$
	Medical Expense Limit (any one person)		$
	Hangarkeeper's Liability Coverage
	Each Aircraft		$
	Each Loss Limit		$
	Deductible
		Each Aircraft $	Total Advance Premium $

Does airport use non-owned aircraft on airport business? Choose One: Yes No If Yes, do employees pilot aircraft on airport business? Choose One: Yes No

Describe types of aircraft flown on airport business:

Number of hours flown annually in all non-owned aircraft on applicant's behalf: By employees: By others:

Number of hours flown in chartered aircraft: By employees: By others:

Number of hours flown in rented/leased aircraft: By employees: By others:

Number of hours flown in borrowed aircraft: By employees: By others:

Provide current pilot experience forms for each employee pilot.

NOTICE TO NEW YORK APPLICANTS: “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, conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.”

NOTICE TO OHIO APPLICANTS: “Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.”

NOTICE TO KENTUCKY APPLICANTS: “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.”

NOTICE TO PENNSYLVANIA APPLICANTS: “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.”

NOTICE TO NEW JERSEY APPLICANTS: “Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.”

NOTICE TO FLORIDA APPLICANTS: “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 in the third degree.”

NOTICE TO COLORADO APPLICANTS: “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 authorities.”

NOTICE TO MINNESOTA APPLICANTS: “A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.”

NOTICE TO ARKANSAS APPLICANTS: “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.”

NOTICE TO MAINE APPLICANTS: “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.”

NOTICE TO NEW MEXICO APPLICANTS: “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.”

NOTICE TO VIRGINIA APPLICANTS: “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.”

All information herein is warranted to be true to the best of my knowledge and no information has been suppressed or withheld, and no insurer has cancelled or refused to renew this insurance. I understand that the information herein and the truthfulness thereof will be the basis of any insurance provided by the Company. This application does not bind the applicant or the Company to provide any insurance.

By typing your name here you agree to apply for Airport Liability Insurance: