AIRCRAFT
INSURANCE
APPLICATION
Applicant’s Name _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mailing Address __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Effective from ______________________ until ______________________ Both at 12:01 AM standard time at the address above.
Business of Applicant ____________________________________________ Number of Years in Business ____________________
Former Business Names ________________________________________________________________________________________________________________________________________________________________________________________________________________________
Applicant is:
n
Individual(s)
n
Partnership
n
Corporation
n
Holding Company
n
Government
n
Other (describe)______________________________________________________
and is owned, controlled, or a subsidiary of_________________________________________________________________________
Is Applicant incorporated solely for ownership of the aircraft?___________________________________________________________
Is applicant IS - BAO certified? ___________________________________________________________________________________
Does applicant meet Wyvern, Argus Safety Audit Standards or any other safety audit guideline?_____________________________________
What is the name of the auditing organization? ______
_______________________________________________________________
APP-05 (rev 3/13)
CONTINUED ON REVERSE SIDE
LIABILITY COVERAGE
___________________________________________________________________________________________________________
n
Bodily Injury Liability
Excluding Passengers $$
n
Property Damage Liability xxxx $
n
Passenger Bodily Injury Liability $$
n
Single Limit ______ cluding Passengers xxxx $
n
With Passenger Liability Limited To: $ xxxx
n
Medical Payments
Crew is:
n
included
n
excluded $$
n
Other Liability (Specify)
___________________________________ $$
Limits of Liability Requested
Each Person Each Occurrence
PHYSICAL DAMAGE COVERAGE
_____________________________________________________ ____________________________________
n
All Risk: Ground and Flight $ $ .00
n
All Risk: Not in Flight $ $ .000.
n
All Risk: Not in Motion $ $ .000.
Amount of Insurance
_________________
(must be equal to
_
current market value)
Deductibles
IN MOTION
INGESTION
0.
MOORED
n
$ 1000.
n
$ 500.
n
$ 250.
n
$____________________________________
Any Other
NOT IN MOTION $_________________________
CHEMICAL LIABILITY COVERAGE
“AERIAL APPLICATION ONLY”
Limits of Liability Requested
Each Person Each Occurrence Aggregate Limit
Bodily Injury Liability Excluding Passengers
Property Damage Liability
Single Limit Property Damage & Bodily Injury,
Excluding Passengers
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
Not Applicable
Not Applicable
$
$
$
$
$
$
$
Chartis Aerospace
Insurance Services, Inc.
AIG Aerospace
Insurance Services, Inc.
PAGE 2
Aircraft usually based at _________________________________________________________________
n
Hangared
n
Tied-out
(Name of Home Airport, give details of runway length, construction & all obstructions)
Estimate hours to be flown in the upcoming 12 months:______________________________________________________________
Estimate average pax load for the upcoming 12 months:______________________________________________________________
If your aircraft is managed by others, please identify the aircraft manager:__________________________________________________
Who employs the aircraft manager?_______________________________________________________________________________
Who employs your pilots?_______________________________________________________________________________________
Name and describe relationship to the named insured:_________________________________________________________________
___________________________________________________________________________________________________________
Does Applicant hangar, service, repair or crew other aircraft? ______ Describe______________________________________________
Are any unapproved airports or unpaved runways used? ______ Describe _________________________________________________
___________________________________________________________________________________________________________
Is any aircraft registered under other names than Applicant's name above? ______ Describe __________________________________
What foreign destinations do you plan to travel to in the next 12 months? _________________________________________________
List all partners and owned, controlled, affiliated and subsidiary firms on separate sheet.
n
List attached
Has any applicant, or officer or partner thereof, or pilot been convicted in or indicted in a legal action involving drugs?________________
Applicant is:
n
Sole Owner of the aircraft
n
Owner subject to mortgage or conditional sales contract
n
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? _________________________________________________________
Are any other Aircraft owned by, rented or used by or on behalf of Applicant?______________________________________________
Model Aircraft______________________________ Uses_____________________________ No. of hours per year_______
PURPOSE OF USE
CHECK ALL APPLICABLE USES
n
Pleasure or
n
Business (not flown by professional pilots employed for this purpose)
n
Instruction
n
Rental (Commercial)
n
Corporate- Executive (flown only by professional pilots employed for this purpose)
n
Flying Club
n
Photography
n
Passenger Carrying for Hire (Charter/Air Taxi)
n
Air Ambulance (Charter/Air Taxi)
n
Freight Carrying (Charter/Air Taxi)
n
Pipeline/Powerline Patrol
n
Banner Towing
n
Aerial Application (see below)
n
List all other uses not indicated above (explain) __
_________________________________________________________________
______________________________________________________________________________________________________________
PILOTS NAMES
All pilots who will regularly operate the insured aircraft must complete a “PILOT QUALIFICATIONS” form:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
APP-05 (rev 3/13)
AIRCRAFT If Airworthiness Certificate is other than Standard or Normal, please indicate category:___________________________
Describe any STC
’s
, modifications or unrepaired damage: _____________________________________________________________
Make & Model Year Registration
Number
Seating
Capacity
Land (L)
Sea (S)
Amphib (A)
Rotorwing (R)
Purchased
New or
Used
Date
Price Paid
By Applicant (inc.
Extras)
Present Estimated
Value
(inc. Extras)
Engine
Hrs. since new,
or since last
major overhaul
Crew Pass.
1.
2.
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?
n
Yes
n
No If so, explain.
(Note: Missouri applicants Do Not Respond)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
AERIAL APPLICATION ONLY
Please fill out this section if you have checked “Aerial Application” under the PURPOSE OF USE Section above
List all states where you conduct aerial application __________________________________________________________________
Describe applicants 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:
Application of Glyphosate ____% Piclorams ____% Hormone Herbicides ____% Insecticides ____% Other ____%
Application to Orchards/Groves ____% Vineyards ____% Forest/Tree Farms ____% Exotic Fruits/Vegetables ____% Other ____%
List all Pilot’s claims, incidents, accidents, FAA Medical Waivers (other than for corrective lenses), FAR violations, DUI and felony convictions
(write “none” if none of the above applies)
paGe 3
app-05 (rev 3/13)
Would you like a Private Client Group representative to contact you regarding your personal life insurance? YES
NO
q q
FRAUD WARNINGS
(last updated 1/13)
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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO ALABAMA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT
OF A LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF
A CRIME AND MAY BE SUBJECT TO RESTITUTION FINES OR CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF.
NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA 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 APPLICA-
TION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
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 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 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 INFORMA-
TION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
NOTICE TO KANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO
BE PRESENTED OR PREPARED WITH KNOWEDLGE 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, AN APPLICATION FOR
THE ISSUANCE OF, OR THE RATING OF AN 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 MATERIAL FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR
THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSUR-
ANCE ACT.
NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COM-
PANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CON-
CEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDU-
LENT INSURANCE ACT, WHICH IS A CRIME.
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 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 MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLI-
CATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICA-
TION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COM -
PANY 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 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 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 §3613.1).
NOTICE TO OREGON 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 IN-
FORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY
BE GUILTY OF A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COM -
PANY 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 TENNESSEE, VIRGINIA AND WASHINGTON 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 IN-
CLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR
INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
APP-05 (rev 3/13)
PAGE 4
FRAUD WARNINGS CONTINUED
(Producer will fill in this information)
Producer _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Address___________________________________________________________________________________________________ City _____________________ State ____________ Zip _____________
Telephone No.____________________________ Fax No. _________________________________________________________
Email Address ____________________________________________________________
paGe 5
app-05 (rev 3/13)
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FRAUD WARNINGS CONTINUED
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