AVIATION SERVICES INSURANCE INTAKE FORM

AVIATION SERVICES INSURANCE

INTAKE FORM

AVIATION OPERATIONS INSURANCE - INTAKE FORM

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Applicant's Name

Business Type

Describe Applicant's Business Activities

Phone Number (Mobile Preferred)

Email Address

Check All Services provided by Your Business

SALES OF EQUIPMENT & PARTS

FUEL & DEFUELING SERVICES

CONSULTING & TRAINING

AIRCRAFT SALES & DISTRIBUTION

AVIATION CLEANING & DETAILING

AIRCRAFT REPAIR & SERVICING

AIRCRAFT STORAGE

AIRCRAFT PAINTING

FOOD & BEVERAGE SALES

AIRFRAME REPAIR OR MODIFICATION

AIRPORT OPERATION

PRIVATE AIRPORT MANAGEMENT

RUNWAY MAINTENANCE

ORGANIZES AIRSHOWS OR EXHIBITIONS

HANGAR OWNER OR LANDLORD

AIRPORT OWNERSHIP

AVIONICS SALES

DE-ICING SERVICES

HANGAR RENTAL

TIE DOWNS

AIRCRAFT TOWING

FLYING CUSTOMERS' AIRCRAFT

RUNWAY MAINTANENCE

FLYING CUSTOMER'S AIRCRAFT

CONSTRUCTION or DEMO of STRUCTURES

Who are Your Typical Customers?

OWNERS / INDIVIDUALS OF AIRCRAFTS & PRIVATE JETS

AIRCRAFT CHARTER COMPANIES

COMMERCIAL AIRLINES

EMERGENCY RESPONDERS

AIRCRAFT RENTAL COMPANIES

AIRPORTS

Select the Different Items Used in Your Business (select All that Apply )

HAND HELD CLEANING SUPPLIES

MOBILE CLEANING EQUIPMENT

BASIC HAND-HELD TOOLS

EXPENSIVE HAND-HELD TOOLS

OTHER TYPES of EQUIPMENT

FUEL TRUCKS

AIRCRAFT TUGS

DE-ICING MACHINES

Is this a New Business?

YES

Number of Years in Business

Has there been any Mergers, Acquisitions, or Changes in Management?

YES

How many Years since the Merger, Acquisition, or Change in Management?

How many Years have You been at Your Current Location?

What is the MAXIMUM Number of Aircrafts Your Business will Service at any One Time?

Select all Who are Responsible for Completing the Work typical to Your Business ( select all that apply )

OWNER or OWNERS

EMPLOYEES

SUB CONTRACTORS ( 1099's )

Number of Owners Completing Work

Number of Employees Completing Work

Number of Individual Sub Contractors Completing Work

Please describe Work Completed by Sub Contractors

Does Your Business Currently have any Insurance?

YES

What Insurance Company Currently provides your insurance? ( please include the Types of Coverage, too )

When does the Policy or Policies Renew?

Mailing Address Information

Street Address

City

State

Zip Code

BUSINESS LOCATION INFORMATION (where you conduct work)

How Many Locations does Your Business does Your Business visit to Conduct Work?

10+

LOCATION # 1

LOCATION 1 : Please provide the address or name of Airport or Facility

Regarding this Location, Does Your Business...

OWN THE PROPERTY

HAS A GENERAL LEASE ON THE PROPERTY

IS A TENANT OR RENTER

NONE OF THESE, ONLY VISITS TO CONDUCT WORK

Regarding this Location, Do you Occupy the Location...

ENTIRELY

PARTIALLY

NONE OF THESE, ONLY VISIT TO CONDUCT WORK

Who is Responsible for the Maintenance of this Location?

MY BUSINESS

RESPONSIBILITY OF OTHERS

UKNOWN

LOCATION # 2

LOCATION 2 : Please provide the address or name of Airport or Facility

Regarding this Location, Does Your Business...

OWN THE PROPERTY

HAS A GENERAL LEASE ON THE PROPERTY

IS A TENANT OR RENTER

NONE OF THESE, ONLY VISITS TO CONDUCT WORK

Regarding this Location, Do you Occupy the Location...

ENTIRELY

PARTIALLY

NONE OF THESE, ONLY VISIT TO CONDUCT WORK

Who is Responsible for the Maintenance of this Location?

MY BUSINESS

RESPONSIBILITY OF OTHERS

UKNOWN

LOCATION # 3

LOCATION 3 : Please provide the address or name of Airport or Facility

Regarding this Location, Does Your Business...

OWN THE PROPERTY

HAS A GENERAL LEASE ON THE PROPERTY

IS A TENANT OR RENTER

NONE OF THESE, ONLY VISITS TO CONDUCT WORK

Regarding this Location, Do you Occupy the Location...

ENTIRELY

PARTIALLY

NONE OF THESE, ONLY VISIT TO CONDUCT WORK

Who is Responsible for the Maintenance of this Location?

MY BUSINESS

RESPONSIBILITY OF OTHERS

UKNOWN

LOCATION # 4

LOCATION 4 : Please provide the address or name of Airport or Facility

Regarding this Location, Does Your Business...

OWN THE PROPERTY

HAS A GENERAL LEASE ON THE PROPERTY

IS A TENANT OR RENTER

NONE OF THESE, ONLY VISITS TO CONDUCT WORK

Regarding this Location, Do you Occupy the Location...

ENTIRELY

PARTIALLY

NONE OF THESE, ONLY VISIT TO CONDUCT WORK

Who is Responsible for the Maintenance of this Location?

MY BUSINESS

RESPONSIBILITY OF OTHERS

UKNOWN

LOCATION # 5

LOCATION 5 : Please provide the address or name of Airport or Facility

Regarding this Location, Does Your Business...

OWN THE PROPERTY

HAS A GENERAL LEASE ON THE PROPERTY

IS A TENANT OR RENTER

NONE OF THESE, ONLY VISITS TO CONDUCT WORK

Regarding this Location, Do you Occupy the Location...

ENTIRELY

PARTIALLY

NONE OF THESE, ONLY VISIT TO CONDUCT WORK

Who is Responsible for the Maintenance of this Location?

MY BUSINESS

RESPONSIBILITY OF OTHERS

UKNOWN

ALL LOCATIONS ENTRY

Please provide the address or names of all Airports or Facilities

Regarding this Location, Does Your Business...

OWN THE PROPERTY

LEASES ON THE PROPERTY

IS A TENANT OR RENTER vON THE PROPERTY

NONE OF THESE, ONLY VISITS TO CONDUCT WORK

Who is Responsible for the Maintenance of this Location?

MY BUSINESS

RESPONSIBILITY OF OTHERS

UKNOWN

Regarding this Location, Do you Occupy the Location...

ENTIRELY

PARTIALLY

NONE OF THESE, ONLY VISIT TO CONDUCT WORK

AIRCRAFT WORK BREAKDOWNS

Types of Aircraft Serviced

FIXED WING & PRIVATE JETS

ROTORWING & HELICOPTERS

COMMERCIAL AIRCRAFT

Types of Fixed Wing Aircraft Serviced

Include Manufacturer and Model Information

Types of RotorWing Aircraft Serviced

Include Manufacturer and Model Information

Types of Commercial Aircraft Serviced

Include Manufacturer and Model Information

List the Manufacturer & Types of Aircraft or Components you Sell or Distribute

Is Your Business, or any of its Owners, a Member of PAMA or SAE International?

YES

Are any of Your Employees PAMA or SAE Certified?

YES

How many Employees are PAMA or SAE Certified?

Do You, the Owners, Executives, or Employees hold any other Certifications, Licenses, or Memberships?

YES

Please describe those Certifications, Licenses, or Memberships here...

Please describe the work involving Engine or Airframe MODIFICATION?

Have You ever Sold, Serviced or Repaired "Ultra-Light" or "Homebuilt" aircraft?

YES

Please describe the work involving "Ultra-Light" or "Homebuilt" Aircraft

FLYINING CUSTOMER'S AIRCRAFT

Regarding the Flying of Customer's Aircraft, please describe this activity

What's the Largest type of Aircraft Flown?

What's the MAXIMUM value for any one Aircraft Flown?

Does Your Business have any separate "Non-Owned Aircraft Liability Insurance?

YES

CONSTRUCTION, DEMOLITION & ALTERATIONS of AIRPORT STRUCTURES

Projected 12 Month Contract Costs for Your Involvement in CONSTRUCTION, DEMOLITION & ALTERATIONS of AIRPORT STRUCTURES

Please describe the Services Provided :

Do You use Sub Contractors in the CONSTRUCTION, DEMOLITION & ALTERATIONS of AIRPORT STRUCTURES

YES

Please describe the Services Provided by Your Sub Contractors :

Projected 12 Month Contract Costs using Sub Contractor involving CONSTRUCTION, DEMOLITION & ALTERATIONS of AIRPORT STRUCTURES

If available, please upload a copy of your Agreement used with Sub Contractors

Max. file size: 16 MB.

TOTAL INCOMING REVENUE

Guesstimated Total Revenue for the Last 12 Months

REPAIR REVENUES

Percentage of Revenue from the Repair of Fixed Wing Airframes & Components

Percentage of Revenue from the Repair of RotorWing Airframes & Components

Percentage of Revenue from the Repair of Fixed Wing Engines & Components

Percentage of Revenue from the Repair of RotorWing Engines & Components

Percentage of Revenue from Major Overhauls

Percentage of Revenue from Hot Section Repairs

Percentage of Revenue from Avionics Repairs

Percentage of Revenue from RotorSystems Repairs

Percentage of Revenue from Propeller Repairs

NEW & USED PART SALES REVENUE BREAKDOWN

Sale of NEW Parts without Installation - Guesstimated 12 month Revenue

Sale of USED Parts without Installation - Guesstimated 12 month Revenue

FUEL & OIL SALES

Sale of Fuel & Oil : Guesstimated 12 month Revenue

Pumping Fees: Guesstimated 12 month Revenue

How many Approximate Gallons per Year

Types of Aircraft FUELED / DEFUELED

AIRCRAFT SALES

Sale of NEW Aircraft (turbine) : Guesstimated 12 month Revenue

Sale of USED Aircraft (turbine) : Guesstimated 12 month Revenue

Sale of NEW Aircraft ( Turbine ) : Guesstimated 12 month Revenue

Sale of USED Aircraft ( Turbine ) : Guesstimated 12 month Revenue

OTHER REVENUE SOURCES

Sale of Food / Beverage : Guesstimated 12 month Revenue

Aircraft Detailing & Cleaning : Guesstimated 12 month Revenue

Airframe Painting - Guesstimated 12 month Revenue

De-Icing Services - Guesstimated 12 month Revenue

HANGARKEEPERS LIABILITY SECTION (coverage for the aircraft your business services)

What's the AVERAGE Value of any one Aircraft Serviced

What's the MAXIMUM Value of any one Aircraft Serviced

What's the AVERAGE Value of all Aircrafts Serviced at any one time

What's the MAXIMUM Value of all Aircrafts Serviced at any one time

Guesstimate the Space that Separates Aircraft being Serviced by You at Any One Time

IN THE SAME HANGAR

AIRCRAFT ARE in DIFFERENT HANGARS

HANGER RENTAL (to others) - Guesstimated 12 month Revenue

TIE DOWNS - Guesstimated 12 month Revenue

AIRCRAFT TOWING - Guesstimated 12 month Revenue

COMMERCIAL AUTOMOBILE INSURANCE INFORMATION

Would you like an Automobile Insurance Quote?

YES

IF AVAILABLE, QUOTE HIRED & NON OWNED AUTOMOBILE LIABILITY ONLY

Does Your Business Own Any Vehicles?

YES

Does Your Business Rent any Vehicles?

YES

OWNED VEHICLE INFORMATION

How Many Vehicles are Owned?

10+

VEHICLE 1 : INFORMATION

Vehicle 1 : YEAR

Vehicle 1 : MAKE & MODEL

Vehicle 1 : VIN

Vehicle 1 : COST NEW

VEHICLE 2 : INFORMATION

Vehicle 2 : YEAR

Vehicle 2 : MAKE & MODEL

Vehicle 2 : VIN

Vehicle 2 : COST NEW

VEHICLE 3 : INFORMATION

Vehicle 3 : YEAR

Vehicle 3 : MAKE & MODEL

Vehicle 3 : VIN

Vehicle 3 : COST NEW

VEHICLE 4 : INFORMATION

Vehicle 4 : YEAR

Vehicle 4 : MAKE & MODEL

Vehicle 4 : VIN

Vehicle 4 : COST NEW

VEHICLE 5 : INFORMATION

Vehicle 5 : YEAR

Vehicle 5 : MAKE & MODEL

Vehicle 5 : VIN

Vehicle 5 : COST NEW

VEHICLE INFORMATION

Please List : YEAR / MAKE & MODEL / VIN / COST NEW for each OWNED VEHICLE

EQUIPMENT USAGE SECTION

Does Your Business Own any Equipment?

YES

Does Your Business Rent any Equipment?

YES

OWNED EQUIPMENT SECTION

Describe Your Owned Equipment Here

What's the Total Value of all Owned Equipment?

What's the maximum Value for any One Piece of Equipment you Own

RENTED EQUIPMENT SECTION

Describe Your Rented Equipment Here

What's the Total Value of all Rented Equipment at any one time?

CLAIMS HISTORY & FEDERAL AVIATION REGULATION VIOLATIONS

Has Your Business Experienced any Claims, whether Insured or Not, or FAR Violations in the Past 10 Years?

YES

Please describe any previous claims along with the Amounts Paid

Please upload LOSS RUNS HERE

Max. file size: 16 MB.