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AIRCRAFT INSURANCE AP LICATION P Insurance Provided by (Risk Placement Services, Inc.)

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APP-05 (02.2005)
Insurance Provided by
Member Companies of
American International Group, Inc.
Applicant’s Name: ____________________________________________________________________________________________
Mailing Address: ______________________________________________________________________________________________
Effective from: __________ until __________ Both at 12:01 a.m. standard time at the address above.
Business of Applicant: ____________________________________________ Number of Years in Business: __________________
Former Business Names: _______________________________________________________________________________________
Applicant is: Individual(s) Partnership Corporation Holding Company Government Other (describe): _____ and is
owned, controlled, or a subsidiary of ______________________________________________________________________________
Is Applicant incorporated solely for ownership of the aircraft? Yes No
LIABILITY COVERAGE Limits of Liability Requested
Each
Person
Each
Occurrence Premium
Bodily Injury Liability Excluding Passengers $ ____________ $ ____________ $ ____________
Property Damage Liability $ ____________ $ ____________ $ ____________
Passenger Bodily Injury Liability $ ____________ $ ____________ $ ____________
Single Limit _____cluding Passengers
With Passenger Liability Limited to:
xxxxxxx
$ ____________
$ ____________
xxxxxxx
$ ____________
Medical Payments
Crew is: Included Excluded
$ ____________ $ ____________ $ ____________
Other Liability (specify): ________________ $ ____________ $ ____________ $ ____________
CHEMICAL LIABILITY COVERAGE Limits of Liability Requested
(Aerial Application Only) Each
Person
Each
Occurrence
Aggregate
Limit Premium
Bodily Injury Liability Excluding Passengers $ ____________ $ ____________ $ ____________ $ ____________
Property Damage Liability Not Applicable $ ____________ $ ____________ $ ____________
Single Limit Property Damage & Bodily
Injury, Excluding Passengers
Not Applicable $ ____________ $ ____________ $ ____________
Check Appropriate Chemical Category: XC-seeds and fertilizers only
RC- Restricted Chemical
CC-Comprehensive Chemical,
including: Farmer/Owner/Grower Adjacent Fields
Crops Treated Picloram
P.D. Claims Reimbursement: $ __________ each occurrence arising from chemicals $ __________ arising from other than chemicals.
PHYSICAL DAMAGE COVERAGE
Amount of Insurance
(must be equal to current
market value)
Deductibles Premium
All Risk: Ground and Flight $ ____________ $ ____________
All Risk: Not in Flight $ ____________ $ ____________
All Risk: Not in Motion $ ____________
In Motion Ingestion
Moored
$1000.00
$500.00
$250.00
Other $________
Not In Motion $ _____
$ ____________
TOTAL POLICY PREMIUM: $ _____________
AIRCRAFT INSURANCE
AP
P
LICATION
APP-05 (02.2005)
AIRCRAFT If Airworthiness Certificate is other than Standard or Normal, please indicate category: _____________________________
Describe any STC’s, modifications or unrepaired damage: _____________________________________________________________
Seating
Capacity Purchased
Make &
Model Year
Registration
Number
Crew Pass.
Land (L)
Sea (S)
Amphib (A)
Rotorwing (R)
New /
Used Date
Price Paid by
Applicant (incl.
Extras)
Present
Estimated Value
(incl. Extras)
Engine Hrs.
Since New, or
Since Last Major
Overhaul
Engine
Make
and HP
1.___
____
___
___
_______
_______
___
___
___
___
___________
___________
___
___
___
___
_________
_________
___________
___________
___________
___________
_____
_____
2.___
____
___
___
_______
_______
___
___
___
___
___________
___________
___
___
___
___
_________
_________
___________
___________
___________
___________
_____
_____
3.___
____
___
___
_______
_______
___
___
___
___
___________
___________
___
___
___
___
_________
_________
___________
___________
___________
___________
_____
_____
Aircraft usually based at: _______________________________________________________________________________________
(Name of Home Airport. Give details of runway length, construction & all obstructions.) Hangared Tied-Out
Does Applicant hangar, service, repair or crew other aircraft? Yes No
If Yes, describe: ______________________________________________________________________________________________
Are any unapproved airports or unpaved runways used? Yes No
If Yes, describe: ______________________________________________________________________________________________
Is any aircraft registered under other names that Applicant’s name above? Yes No
If Yes, describe: ______________________________________________________________________________________________
Describe all navigation outside the United States and Canada. _________________________________________________________
___________________________________________________________________________________________________________
List all partners and owned, controlled, affiliated and subsidiary firms on separate sheet. List attached.
Has any applicant, or officer or partner thereof, or pilot been convicted in or indicted in a legal action involving drugs? Yes No
Applicant is: Sole Owner of the aircraft
Owner subject to mortgage or conditional sales contract
Other (explain): _______________________________
If aircraft is mortgaged, name and address of mortgagee: _____________________________________________________________
Amount of mortgage (excluding interest and finance charges) $ ________________________________________________________
Will Breach of Warranty Coverage be required by mortgagee? Yes No
Are any other Aircraft owned by, rented or used by or on behalf of Applicant? Yes No
If Yes: Model Aircraft ____________________________ Uses _________________________________ No. Hours per Year _______
PILOT(s) NAMES
All pilots who will regularly operate the insured aircraft must complete a “Pilot Qualification” form. List all names below.
1. _____________________________________________ 3. _________________________________________________________
2. _____________________________________________ 4. _________________________________________________________
PURPOSE OF USE (Check all Applicable Uses)
Pleasure or Business (not flown by professional pilots employed for this purpose)
Corporate – Executive (flown only by professional pilots employed for this purpose)
Instruction Rental (Commercial) Flying Club Photography
Passenger Carrying for Hire (Charter / Air Taxi) Air Ambulance (Charter / Air Taxi)
Freight Carrying (Charter / Air Taxi) Pipeline / Powerline Patrol
Banner Towing Aerial Application (SEE BELOW)
List all other uses not indicated above (explain each): ______________________________________________________________
APP-05 (02.2005)
AERIAL APPLICATION ONLY
Please fill out this section only if you have checked “Aerial Application” under the PURPOSE OF USE section above.
List all states where you conduct aerial application: __________________________________________________________________
Describe applicant’s violation of any law or regulation governing aerial application operations: _________________________________
Describe any owned/operated ground spraying equipment and type of use: _______________________________________________
Show the percentage each represents to the total (100%):
Application of Glyphosate _____% Piclorams _____% Hormone Herbicides _____% Insecticides _____% Other _____%
Application to Orchards/Groves ____% Vineyards ____% Forest/Tree Farms ____% Exotic Fruits/Vegetables ____% Other____%
Name of last Aircraft Insurance carrier (if none, so state): ______________________________________ Exp. Date: ______________
Describe all incidents, accidents, claims (hull and liability) with dates and amounts paid (even if none), which occurred in the last five
years. ______________________________________________________________________________________________________
Has any Insurance Company or Underwriter at any time declined an aircraft application submitted by or cancelled or refused to renew
an aircraft policy held by the applicant or any of the pilots named herein? Yes No
If Yes, explain. (Note: Missouri applicants Do Not Respond) ___________________________________________________________
NOTICE TO 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 act, which is a crime,
and subjects such person to criminal and civil penalties.
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 ARKANSAS AND 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 fines and confinement in prison.
NOTICE TO UTAH APPLICANTS: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability
compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines
and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to kn owingly 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 TENNESSEE AND 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO LOUISIANA 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 OKLAHOMA APPLICANTS: 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 (365: 15-1-10, 36 S.S. 3613.1)
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.
Applicant Signature Today’s Date
To Be Completed By Producer
Producer: ___________________________________________________________________________________________________
Address: _______________________________________________ City: ____________________ State: _____ Zip: ____________
Telephone Number:____________________ Fax Number: _____________________ E-mail: ________________________________
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APP-01 (02.2005)
PILOT QUALIFICATIONS
Insurance Provided by
Member Companies of
American International Group, Inc.
Named Insured
___________________________________________________
Make & Model of Aircraft to be Flown
________________________________________________________
Your Name
___________________________________________________
Home Address
________________________________________________________
Date of Birth
___________________________________________________
List Diplomas/Degrees
________________________________________________________
Occupation
___________________________________________________
Percent of Work Time Spent on Non-flying Duties
________________________________________________________
Employed by
___________________________________________________
Since (Year) _______
Full Time Part Time (Check One)
Business Address
___________________________________________________
Business Phone
___________________
Home Phone
___________________
List Employers & Positions Held Over the Past 5 Years _________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
AIRMAN CERTIFICATE NUMBER MEDICAL
Number: ___________________________________________ Class: __________________________________________________
Limitations: _________________________________________ Expiration Date: __________________________________________
Limitations: ______________________________________________
CURRENT CERTIFICATES & RATINGS
Student: Since (date) _____ Instrument: Class _____ Multi Engine – Sea
Private Night Type Aircraft rated in _____
Commercial Single Engine – Land Rotorcraft
Sr. Commercial Single Engine – Sea Glider
Airline (ATP) Center Line Thrust A & P Mechanic
Instructor: Class _____ Multi Engine – Land Other _____
Date of last logged satisfactorily accomplished Biennial Flight Review : __________ Make & Model: _____________________________
Date of last logged satisfactorily accomplished Pilot Proficiency Exam: __________ Make & Model: _____________________________
FLIGHT & GROUND SCHOOL TRAINING COURSES
Name & Location of School _______________________________________________________________________________________
Type of Aircraft _____________________ Date ________________ Graduated? _______ (yes/no)
Initial Type Training Recurrency Training Full-axis Motion Flight Simulator Training Ground School Only Aerial Applicator
School
Name & Location of School _______________________________________________________________________________________
Type of Aircraft _____________________ Date ________________ Graduated? _______ (yes/no)
Initial Type Training Recurrency Training Full-axis Motion Flight Simulator Training Ground School Only Aerial Applicator
School
Name & Location of School _______________________________________________________________________________________
Type of Aircraft _____________________ Date ________________ Graduated? _______ (yes/no)
Initial Type Training Recurrency Training Full-axis Motion Flight Simulator Training Ground School Only Aerial Applicator
School
AERIAL APPLICATOR
Number of years experience as an aerial applicator pilot ________________________________________________________________
Total hours applying: herbicides _______________ insecticides ___________________
List states in which you are currently licensed to conduct aerial application. __________________________________________________
APP-01 (02.2005)
Explain any suspension or revocation of any state aerial applicator certificate held by you.
_
_____________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
LOGGED PILOT HOURS
Total Pilot-In-Command Hours for All Aircraft _________________________________________________________________________
ITEMIZATION PILOT-IN-COMMAND HOURS
CLASS
MAKE &
MODEL TOTAL
LAST 90
DAYS
LAST 12
MONTHS
INSTRUMENT 6
MONTHS
CO-PILOT
HOURS
INSURED MAKE/MODEL
_____________ _____________ _____________ _____________ _____________ __________
SINGLE ENGINE
FIXED-GEAR
_____________ _____________ _____________ _____________ _____________ ___________
SINGLE ENGINE
RETRACTABLE
_____________ _____________ _____________ _____________ _____________ ___________
MULTI ENGINE PISTON
_____________ _____________ _____________ _____________ _____________ ___________
TURBO-PROP
_____________ _____________ _____________ _____________ _____________ ___________
JET
_____________ _____________ _____________ _____________ _____________ ___________
HELICOPTER – RECIP –
TURBINE – SLING LOAD
_____________ _____________ _____________ _____________ _____________ ___________
NUMBER OF WATER
LANDINGS & TAKE-
OFFS
_____________ _____________ _____________ _____________ _____________ ___________
ANSWER ALL QUESTIONS
Any person who knowingly and with intent to defraud any insurance company or other person who files an application for
insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime.
1. Have you ever had an aircraft claim, incident, or accident? YES NO
2. Have you ever been cited or fined for violation of an aviation regulation? YES NO
3. Has your pilot certificate ever been suspended or revoked? YES NO
4. Have you ever been convicted of a felony or are you under indictment for a felony? YES NO
5. Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics, or of reckless driving? YES NO
6. Has your drivers’ license ever been suspended or revoked? YES NO
7. Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics? YES NO
8. Have you ever had or been treated for a chemical dependency? YES NO
9. Are you regularly using any medication? YES NO
Explain fully each “YES” answer.
_____________________________________________________________________________Continue on additional pages as needed.
ALL OF THE IMFORMATION HEREIN IS TRUE & CORRECT TO THE BEST OF MY KNOWLEDGE AND I HAVE NOT KNOWINGLY
OR INTENTIONALLY CONCEALED OR MISREPRESENTED ANY FACT. THIS FORM WILL BECOME PART OF THE INSURANCE
APPLICATION AND AS SUCH ALL FRAUD STATEMETNTS ARE APPLICABLE.
Pilot Signature Today’s Date
FOR INTERNAL USE ONLY
Producer: ____________________________________________________________________________________________________
Address: ___________________________________________________ City: ______________________ State: _____ Zip: ________
Telephone Number: _____________________ Fax Number: ___________________ E-mail: ________________________________
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AIRCRAFT INSURANCE AP LICATION P Insurance Provided by (Risk Placement Services, Inc.)

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Completed 30 July 2020

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