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AIRCRAFT HULL & LIABILITY INSURANCE APPLICATION (Risk Placement Services, Inc.)

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AIRCRAFT HULL & LIABILITY INSURANCE APPLICATION
Street:
City:
Zip Code:
State:
Applicant Name:
Page 1 of 5UW001 (06-12)
Business of Applicant:
Policy No. (if known)
to
Effective from
Liability Coverage (for Aerial Applications, complete Chemical Liability in Aerial Section) Each Person Each Occurance
Bodily Injury - Excluding Passengers $ $
Property Damage $
Passenger Liability $ $
Single Limit Bodily Injury
$
$
Medical Expenses
$ $
$ $
Excluding Passengers and Property DamageIncluding
Excluding Crew
Hours flown last 12 months:
Est. hours flown next 12 months:
Est. passenger load next 12 months:
Engine Make/Type:Engine Hours:
Since New
Since Major Overhaul
Zip Code:State:City:
Address:
Lienholder Name/Attn:
Applicant is:
Sole Owner Lessee Owner subject to Lien Other
explain:
Aircraft based at (identify):
Runway Length in feet:
Public
Private
PavedHangard Angle of attack indicator
TCAS / TIS
TAWS / GPWS
Aircraft Equipment: If operated for hire, percentage of use:
Passenger:
Cargo:
Instruction:
Rental:
%
%
%
%
%
Other:
Amount of Lien (excluding interest and charges): $
Breach of Warranty Required?:
Yes No
Describe any STC's, modifications or unrepaired damage:
If Airworthiness Certificate is other than Standard, please identify category:
Deductibles
In Motion
Not-In-Motion Ingestion
All Risk Ground and Flight
All Risk Ground Not In Flight
All Risk Ground Only
All Bodily Injury Limited to:
Other Liability:
Agreed Value
Physical Damage Coverage
Make/Model
FAA No.:
Year: Crew
Pass.Purchase Year:
New Used Land Sea Amphib
Seating Capacity:
Describe any STC's, modifications or unrepaired damage:
If Airworthiness Certificate is other than Standard, please identify category:
Deductibles
In Motion
Not-In-Motion Ingestion
All Risk Ground and Flight
All Risk Ground Not In Flight
All Risk Ground Only
Agreed Value
Physical Damage Coverage
Make/Model
FAA No.:
Year: Crew
Pass.Purchase Year:
New Used Land Sea Amphib
Seating Capacity:
$$$$
$$$$
Aircraft 1
Aircraft 2
Passenger Bodily Injury Limited to:
Post Office Box 440757
Kennesaw, Georgia 30160
1990 Vaughn Road, Suite 350
Kennesaw, Georgia 30144
Liability Coverage (for Aerial Applications, complete Chemical Liability in Aerial Section) Each Person Each Occurance
Bodily Injury - Excluding Passengers $ $
Property Damage $
Passenger Liability $ $
Single Limit Bodily Injury
$
$
Medical Expenses
$ $
$ $
Passenger Carrying for Hire (Charter/Air Taxi)
Corporate-Exectutive (flown by professional pilots employed for this purpose)
Pleasure or
Air Ambulance / EMS
Business (not flown by professional pilots employed for this purpose)
Aerial Photography
Flying Club
Sightseeing
Aerial Application (see Aerial Application section)
List other uses not indicated:
Freight Carrying (for hire)
Pipeline / Powerline Patrol
Instruction
Electronic News Gathers / Traffic Watch
Banner Towing
Yes No
Will aircraft be operated at other than paved airports?
Will aircraft be operated outside the 48 contiguous states of the U.S.A?
Yes No
Where, surface and length of runway:
Where, purpose and length of frequency:
If 'Yes', explain:
Yes No
Does applicant or employees (including employee pilots) use non-owned aircraft?
Model Aircraft:
Use(s):
Hours of use per year:
Yes No
Do you request a certificate of insurance?
Yes No
Do you charter aircraft on company business?
If your aircraft is managed by others, please identify the manager:
If 'Yes', explain:
Yes No
Are any turbine aircraft operated with a single pilot crew Part 135?
Who employs your pilots?:
Name and describe your relationship to the Named Insured:
Yes No
Does applicant hangar, service, repair or crew other aircraft?
If 'Yes', explain:
1:
List the pilots who operate the insured aircraft. Please complete a “Pilot History Form” for each pilot.
2:
3:
4:
5:
6:
If 'Yes', explain:
Yes No
Are any aircraft registered under other names than applicants name?
Min Liability Limit you will accept from the operator: $
Purpose of Use
Hours flown last 12 months:
Est. passenger load next 12 months:
Est. hours flown next 12 months:
Engine Make/Type:
Engine Hours:
Since New
Since Major Overhaul
Zip Code:State:
City:
Address:
Lienholder Name/Attn:
Applicant is:
Sole Owner Lessee Owner subject to Lien Other
explain:
Aircraft based at (identify):
Runway Length in feet:
Public
Private
Paved
Hangard
Angle of attack indicator
TCAS / TIS
TAWS / GPWS
Aircraft Equipment: If operated for hire, percentage of use:
Passenger:
Cargo:
Instruction:
Rental:
%
%
%
%
%
Other:
Amount of Lien (excluding interest and charges): $
Breach of Warranty Required?:
Yes No
For additional aircraft please attach an "Aircraft Fleet Addendum"
Aircraft Fleet Addendum Attached
Page 2 of 5UW001 (06-12)
Aircraft Operations
Excluding Passengers and Property DamageIncluding
Excluding Crew
All Bodily Injury Limited to
Other Liability
Pilots
Passenger Bodily Injury Limited to
Has applicant of any of the applicant's pilots ever paid, or had paid on
their behalf, any settlement for claims arising out of the Chemical
Liability Hazard (chemical drift coverage) insurance?
Chemical Liability Coverage Each Person Each Occurance
Aggregate
Bodily Injury Excluding Passengers, Excluding Chemical
Bodily Injury Excluding Passengers, Including
Property Damage Excluding Chemical
Property Damage Including
Combined Single Limit Bodily Injury/Property Damage Excluding chemical
Combined Single Limit Bodily Injury/Property Damage Including chemical
Comprehensive ChemicalLimited Chemical
Comprehensive ChemicalLimited Chemical
Comprehensive ChemicalLimited Chemical
What percentage of total application hours during the policy period involve:
Herbicides: Fungicides:
%
Insecticides
Fertilizers:
%
%
%
Membership of any Other Associations
Attended PAASS
Industry of State Plant Board Seminars
Training in the Use of Chemicals
Recurrent Training of Pilots
Yes No
Are you a member of the National Agricultural Aviation Association?
Yes No
Are you a member of a State Aerial Aviation Association?
Page 3 of 5UW001 (06-12)
List states where aerial application will be made:
Attach a completed Flying Roster as of policy inception which must include: Full Name, Age, Certification, Endorsements, Ratings(s), Total Hours
Logged, Retractable Gear Hours, and Conventional Gear Hours (if applicable), Club Aircraft the pilot will operate, and is the pilot a club member
or officer and officer position held.
Pilots
Are members all equal owners of the aircraft?
Does the club have written by-laws?
Does the club designate specific CFI's for instructions to members?
Yes No
Yes No
Yes No
If "Yes" attach a copy.
If "Yes" identify on pilot roster.
Flying Club Applicants Only
Use
Annual
Hours
Use
Annual
Hours
Use
Annual
Hours
Business and Pleasure Offshore/oil rig Logging
Industrial Aid (Corporate) Law Enforcement/police Heli-skiing
Air Ambulance In-flight pick-up/delivery Sightseeing/air tours
Aerial Application Forest service/BLM Seismic oil/gas exploration
Instruction Search and Rescue Firefighting/sire support
Rental Traffic Watch Movies/cinematography
Air Taxi Pipeline/powerline patrol Aerial photography
External load/slung cargo Electronic news gathering Crew training
Utilization
Helicopter Applicants Only
NoYes
Yes No
Has any such claim been made that is still unsettled?
Airport Premise Liability Coverage Each Person Each Occurance
Aggregate
Premise Bodily Injury $ $
Premise Property Damage $ $
Combined Limit Premises Bodily Injury & Property Damage $
If 'Yes', explain:
If 'Yes', explain:
Aerial Application Applicants Only
Other users, explain:
check uses for which coverage is desired and indicate estimated annual hours for each category:
$
$
$
$
$$
$
$
$
$
explain:
explain:
explain:
explain:
explain:
explain:
explain:
Additional Information or Remarks:
Page 4 of 5UW001 (06-12)
Yes No
Yes No
Yes No
Yes No
Yes No
If 'Yes', explain:
Has any such claim been made that is still unsettled?
If 'Yes', explain:
Has applicant or any of applicant's pilots ever paid, or had paid on their behalf, any settlement for claims arising out of the
Chemical Liability Hazard (chemical drift coverage) insurance?
If 'Yes', explain:
Has any insurer cancelled, declined, sent notice of cancellation, or refused to renew any aviation insurance?
If 'Yes', explain:
Has any such claim been made that is still unsettled?
If 'Yes', explain:
Has applicant had any aircraft/aviation losses, claims or incidents during the last five years?
Name of
Last or
Present
Aircraft Insurance Company:
Expiration Date:
Date of Occurance Amount Paid Description of Loss
Loss History and Previous Aviation Insurance
Two axis stabilization system. List Aircraft:
IFR Equipped. List Aircraft:
Floatation/pop out floats. List Aircraft:
High visibility rotor blades. List Aircraft:
Helicopter Applicants Only cont'
Date:Signature:
Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and
VA, insurance benefits may also be denied)
In 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 any insurance company
who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the
policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies.
In the District of Columbia, WARNING: 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.
In 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.
In 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.
In Kansas, any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by
an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, any application for the issuance of, or the rating of any
insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance
which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act.
In Massachusetts, Nebraska, Oregon and Vermont, any person who knowingly and with intent to defraud any insurance company or another 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,
may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.
In Minnesota, any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
In Ohio, any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or
deception statement is guilty of insurance fraud.
In Oklahoma, WARNING: 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.
In 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.
Applicant Name:
Page 5 of 5UW001 (06-12)
FRAUD WARNINGS
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.
Applicant Signature:
Date:
All Owners Must Sign. The Applicant's agent may not sign this Application for the applicant.
This application does not commit the Company to any liability nor make the Applicant liable for any premium unless the Company agrees to affect this
insurance.
Zip Code:
State:City:
Street:
Producer Name:
Phone
Fax:
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AIRCRAFT HULL & LIABILITY INSURANCE APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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